 This is obviously a topic where there's a huge amount of territory that we could we could talk about this for hours and hours and not be done. I've got 45 minutes so I'm going to try to at least do a decent job of scratching the surface on how we can think about medical care from a market perspective and think about some of some of the problems some of the criticisms of markets. I have structured this as four principles for reforming medical care and there's each of these could be a lecture in itself but I want to talk a little bit about free pricing. That's not a hard sell with this audience that prices ought to be able to move around and some of the criticisms we see about pharmaceutical prices I think it is a spurious complaint about markets. Eliminating occupational licensure we'll talk about that in a minute, disbanding barriers to innovation and then finally putting patients instead of government in charge of care. So let's talk first about free pricing. Again not a not a hard sell to this crowd so I won't spend a lot of time here but you know if you've had even a mainstream economics course that if you keep prices below an equilibrium you're going to tend to have shortages that's going to reduce the incentive to create innovative solutions to medical problems that's going to tend to create a waiting in line. One of the things that we see in nations that have adopted a more socialist form of medical care than we have in the United States and I say that because we do not have a free market medical system in the United States that we see in those countries more of a problem with waiting in lines for medical care. If you want to see a specialist in some countries you may wait months. During which time you are getting perhaps worse with your condition. So this is one of those things that I think would go a long way toward improving medical cares is simply allowing prices to move however high they go and forget about arguments that say that pharmaceutical companies are price gouging because of greed. They're price gouging if you want to use that term which I really don't like. They're raising their prices because the government creates barriers to entry for them. We'll talk about those in a minute as well. If you have lower prices we run out of either medical goods such as drugs or we run out of services in a sense. We run out of doctors and nurses and other medical professionals who might have a limit on how many of those people we have at least in the short run. So if you artificially lower the prices of those goods and services you don't get enough for those that might have a great need. So prices serve as a rationing system. Finally the expectation that prices will be capped by the government discourages stock piling for emergencies. So suppose you have the possibility of some kind of outbreak of a disease that might require, I don't know, ventilators in large quantities. And nobody has bothered to put aside an extra stock of these medical devices because the manufacturers and the owners of these devices know that when the need arises they're not going to be able to raise the price to meet the demand. So why incur that cost of stock piling what would ordinarily be idle inventory if you can't raise your price later? So this basic model, the mechanics of price controls indicate that if you keep the price at the customary level even when the situation changes you're going to create these shortages. So if the blue demand and supply curves here are the ones that you normally see when there's a no pandemic, no unusual situation, and then you get an increase in demand and or decrease in supply because of some unusual circumstance. But if the government says well no you can't raise the price to meet that higher equilibrium price then you're creating a shortage. So you have people that might need this good or the services of medical professionals that can't get those goods or services because you've created the environment for a shortage to emerge. Second proposal would be to eliminate occupational licensure. This is not as controversial when it comes to something like cosmetologists which are in many states licensed. You have to go through extensive time-consuming, expensive training to gain certificate or license to do that work. And we think well you know how much damage can you do if you do that work badly we can sort of understand dispensing with occupational licensure doesn't seem to make very much sense at all. But then when it comes to medical care people say well you know with doctors and nurses it's different we need to have licenses to guarantee quality. What that does instead is sort of limit the competition and the innovation that might otherwise occur in medical care. We have actually seen this. The common justification for occupational licensure is that you're protecting patients against incompetence. When in fact you may be protecting the incompetence from an innovator that comes along and questions that status quo. Under pandemic conditions we have seen interestingly I think a questioning of occupational licensure from some unexpected quarters. People who may be skilled but let their licensure lapse maybe they're retired or something can't easily get back into the business of treating patients even though they may have the requisite expertise. Skilled people who are able to perform a function maybe are actively working in the medical field broadly speaking are unable to perform another function because it falls under a different category of licensure. So you're a nurse but you can't do some things legally that a doctor is licensed to do even though you're perhaps skilled enough to do a passable job of it. In an emergency especially there would be no reason to stop someone from helping out where there is an extreme need. And then you may have people who are almost finished with medical school or they've got a lot of their training but they're not licensed yet and they might be able to perform some of these functions but they can't help out even in a crisis because the government will not allow them to. I said from unexpected quarters this is the OECD saying that 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 thereby allow them to spend their time more effectively on the most complex cases. We may see out of this pandemic a weakening of occupational licensure in the medical field for this reason. I hope so. The history of medical licensure is interesting and a good place to start in looking at this is Ronald Hamilley's article from a long time ago but it's a great piece where he says that competition in the pre-medical licensure days in the United States resulted not only in a proliferation of medical personnel but in the growth of heterodox theories arising in opposition to standard medical therapeutics. By the 1870s mainstream medicine had largely dispensed with ineffective and harmful practices like bloodletting using arsenic in treatment and then they began to add botanical drugs along the lines of an alternative school of thought called eclecticism. So this was helpful to patients first do no harm don't bleed them to death and don't give them poisons and that would be one place to start. In the late 1800s again in the pre-licensure days the United and I say pre-licensure we had some states that had some form of licensure but it was fairly easy to get a license even in those states and at that time in the late 1800s the United States had the highest number of physicians per capita in the world but if you are already a doctor and you keep seeing these new doctors flowing into your profession competing with you keeping your fees down you might have some objections to this. So there began to be a movement towards medical licensure and in 1904 the American Medical Association began a concerted effort to reduce the number of medical students. The idea was we won't have as many doctors but the ones we have will be higher quality. Forgetting of course that the competition the sheer number of doctors forced people to be innovative incentivized the kind of thinking outside the box that had produced so much medical progress in the 19th century. In 1910 Abraham Flexner produced a report for the Carnegie Foundation on medical education and the result of this was a crackdown on the amount of or the number of medical schools the number of doctors that were entering the profession diminished after this this creation of a bottleneck in medical education. Any new medical school then had to be approved by the state government. The number of seats in that medical school was limited states began to more rigorously licensed medical professionals and even today the AMA controls medical entry by using their accrediting body called the liaison committee on medical education. So licenses are only granted to members or graduates of those schools so very convenient if you are in a profession that or you can you can limit your competition which is effectively what's happening. Of course the prices of medical care shot up schools of alternative medicine were severely disadvantaged by this many of them were closed only a few survived and then changes arising from this Flexner report meant that there were fewer women and fewer African-Americans coming into the medical profession. So the damage to the consumer of medical care the patient was severe not to mention those who were trying to again think outside the box. Third proposal would be to dismantle barriers to innovation. Now this is where I pick on the FDA which is one of my favorite targets. They create barriers to entry that's what they're in the business of doing. If you want to get a new drug on to the market you may have to pay hundreds of millions of dollars in costs largely because of FDA requirements. New drugs therefore face this immense hurdle before they can get into common use and even if you have an existing drug that you discover a new use for you can't advertise it for that purpose unless you get FDA approval for use in that new role. There's less competition for existing treatments and existing drugs which means that the manufacturers of these drugs can drive up the the price. I get sometimes these comments from from students about how well see the free market and medical care is really bad because you see that when these companies they sell their drugs they sell them for extraordinarily high prices and that's why we need government to control prices. Well you know maybe if we got rid of the the barriers to entry for pharmaceutical products the prices wouldn't be that high because we wouldn't we would see more competition but get rid of the existing government intervention that's allowing firms to do this in the first place and and encouraging it really. Not only that we we get delays in in the innovation it can take years before drugs are approved even with a fast track on coronavirus vaccines we're still seeing these long delays and by the way I'm not taking a position on the pros or cons of the vaccine I'm just pointing out that the FDA is if you're one of these people that says well you know I don't understand why my 11 year old child can't can't get the vaccine well you know government's telling you that you can't give the vaccine to children that age. So this is this is not the market at work. If the market were at work you could decide when you wanted to use this new product and not leave that up to bureaucrats who face incentives to delay. Costs can discourage new drugs we call this drug loss as opposed to the drug lag that we see when drugs are delayed in admission to the market. This costs lives. For example, Sceptra which is an antibiotic was delayed for five years due to FDA requirements and as a result of this according to one estimate by Nobel laureate George Hitchings this delay cost 80,000 lives in the United States alone. Beta blockers which are now in common use the lag in FDA approval may have cost 250,000 lives. Now we don't know exactly who these people are that died. We know how effective these drugs are and we can estimate that had they been available earlier they would have been effective in saving a quarter million lives. Bartley Madden in his book free to choose medicine from 2018 says that costs of the FDA include patient harm from delayed access as well as research and development opportunities foregone by drug developers whose capital is consumed by fulfilling the demands of FDA clinical trials. According to Mary Ruart 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. A number of years ago there was a case in which a doctor at a Boston Children's Hospital wanted to use a nutritional supplement for premature infants. It had already been used in Europe to apparently great effect and the only way he could use it in the United States was on an experimental basis with very limited or conditions that forced very limited use. Why wouldn't the company that made it and sold it in Europe also sell it in the United States? Well of course the FDA but why wasn't the company trying to get the drug approved in the United States? Because they weren't they weren't they weren't even trying. The United States is a very lucrative market lots of people here willing to pay a lot of money for for these kinds of innovations and yet this drug was not even in the pipeline for FDA approval because the company said well you know we've got this this other drug that we're working on that we think will be even better and if we're going to spend all that money to get FDA approval we're going to spend it on that one and not this one that we have right now. Even with very conservative assumptions Ruart found that the years of life lost due to FDA clinical demands is in the millions. So what would we do without the government to help help keep us safe? Live longer. Tom DiLorenzo said new drugs do consumers no good if they don't know about them. Advertising restrictions imposed by the FDA prop up the profits of incumbent drug marketers at the expense of newcomers in the industry and of consumers. A good example of this is a folic acid. A folic acid is now in common a common recommendation for pregnant women because of the needs of the baby for this this vitamin. So if you're deprived of folic acid in pregnancy then the child can have severe birth defects. Had folic acid manufacturers been permitted to advertise we might have seen a decrease in birth defects in the United States but because they weren't allowed to do so without an expensive drug development process we had approximately 10,000 American babies born with deformities that were far worse than the ones caused by thalidomide. Thalidomide is sort of the FDA's great case for how they protected Americans. It was on the way to approval and then they discovered that it created these caused these birth defects and so ever since then it's been a story of the FDA because it dragged its feet of thalidomide protected Americans from birth defects that were seen in other countries that had approved the drug earlier. Nobody really thinks about the 10,000 birth defects caused by the delays in or the ban on advertising folic acid as a nutritional supplement for pregnant women. Thinking about the coronavirus epidemic again we can see where barriers created by the federal government made it more difficult for people to deal with the epidemic early on. Charles Silver and David Hyman wrote that the federal government botched the process for creating and administering coronavirus tests. A new test was needed. German researchers had developed one in mid-January but the CDC 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. It's kind of a my way or the highway approach with these kinds of innovations. The CDC also distributed the few test kits equally to labs across the country without regard to the size of local populations. The result was a dramatic shortage of valid tests in populous areas which created the false impression that the number of cases in the U.S. was low. In early March facilities in the U.S. had administered 3,099 tests by comparison. South Korea, a much smaller country whose epidemic had started the same day as ours had administered 188,000. Now there is a whole discussion that you might get into at some point during this week on intellectual property. I will not get into all of that here. There are people you should read on this like Stefan Kinsella who's written extensively on intellectual property and I've learned a lot from him and others in thinking about this but this touches on the problems that we see with drug development because we see patents in pharmaceutical products. So according to a U.S. CDC survey of the 10 most important medical discoveries of the 20th century, none of them had anything to do with patents. Nathan Nicolayson has an article in Mises Daily which I think is still there. It's about eight years old now but it's an interesting piece on why patents aren't as necessary as we tend to think they are for medical innovation. And because firms find it easy to lengthen the term of the patent by various legal techniques, they're able to preserve that barrier to entry longer than you might expect. A survey of research and development labs and company managers revealed that between 23 and 35 percent believe a patent is an effective way of getting a return on an investment. At the same time 51 percent believe trade secrets to be an effective way of ensuring returns. So what would happen if we got rid of patents? Would we see less innovation because of this absence of the carrot of a temporary monopoly granted by the government? Or would we see lower prices and continuing innovation because of the other incentives that firms have to develop new and innovative products? All right. Fourth suggestion is that we put patients instead of government in charge of care. We have in the United States and have had mainly since the end of World War II a third-party payer system where either private insurance or some form of government payment is accounting for the vast majority of the dollars flowing into medical care provision. And this creates what's called a moral hazard effect. So moral hazard occurs when someone else is bearing the costs of decisions that you make and therefore is affecting your incentives to care about costs. So if I know I have insurance against damage to my car, and let's suppose I have no deductible or a very small deductible, I might park my car on the street where it's more likely to get sideswiped by a passing vehicle because, hey, if that happens, not as much my problem. So when you're shopping for medical care, how much do you care about the cost? I told the story last year about when I had to get an MRI one time for a not-too-serious back problem. I went to the doctor and the doctor said, well, we think you need to get an MRI. I said, okay. He said, call this number, schedule an appointment. I did. I think I was in there the next day. Try that in some countries. And I got my MRI. I don't recall even asking about the price. I looked at the bill later. It's like several thousand dollars MRI. And why didn't I care? Well, I knew it was covered by insurance. And my part of that bill was very, very small. Had I been required to pay that full price out of pocket, first of all, it wouldn't have been that high, probably. And then secondly, I would have said to the doctor, do you think you might be able to get by with an X-ray? Maybe the X-ray is like 98% as effective as the MRI. I don't know. But maybe it's largely as effective than 2% of the cost, in which case we get much more efficient medical care than we would otherwise. I should clarify some terms here. As we start talking about government provision of medical care, there's a lot of confusion about terms. We toss around this term, socialized medicine. We talk about universal coverage. We talk about single payer systems. These are not all synonyms for each other. Socialized medicine means that the government actually operates the hospitals and the medical staff or government employees. Strictly speaking, that's what socialized medicine is. So look at the VA system, for example, the UK's, NHS, the Spanish system, that would qualify as truly socialized medicine. Universal coverage means everybody's got medical insurance, typically provided by the government, but not necessarily. Hospitals, medical staff might be private, often are in universal coverage systems. And then there's the single payer system where you can see this in conjunction with universal coverage, but universal coverage doesn't have to be single payer. You might see a blend of private insurance and some government paid services. What we see in thinking about third-party payers, whatever form that takes, is that we've seen an increase in the amount of medical care being provided or paid for by private insurance or government insurance and a much smaller fraction over time paid for by the person who's receiving the care. So if you go back to 1960, it's about half and half. About half of your medical care would be paid out of pocket. About half was paid by some third party. Today it's closer to 10%. So 90% of what you pay for medical care is paid indirectly through your tax dollars, through your insurance premiums. Your incentive then to care about the cost of a medical procedure is greatly diminished because you know that you're not paying for the vast majority of it. Now some people don't have insurance and they may be paying a much higher fraction out of pocket personally. And for people without insurance, they may care a great deal about the cost. And often medical providers will think about that and charge a lower price. My father was a physician. I know he worked out lower cost for patients that were in dire straits. And so that can happen. Thinking about cosmetic surgery where we often don't see third party payers, where someone is electing to have this procedure done, what do we actually see in terms of costs? Because the patient with a cosmetic procedure is much more likely to be paying out of pocket, that person is much more likely to be thinking about the price and to be price sensitive. And we see that with cosmetic procedures, the costs have not gone up as fast. In fact, in some cases have gone down, not only in absolute terms, but also in relation to other medical services. So if you look at the top of this table here, you see the CPI for hospital services. And over a period from 1998 to 2016 that went up almost 180%. Medical care services about 100%. And then all items in the CPI, food, gas, telephone bills, everything else, 47.2%. So what do we see for cosmetic procedures? I mean, the top ones that are most often paid for are Botox, laser hair removal, and chemical peels. And this is ranked by the number of procedures. So you can see that here. Then we have liposuction, laser skin resurfacing, breast augmentation, sclerotherapy, etc. So what's happened here is a decline in the price of most commonly used procedures. And then you see, for example, liposuction here at 30.6%. Pretty far below the full CPI and very far below hospital and medical care services in general. So relative to other medical care, this is getting a lot cheaper. The average plastic surgery price increase 32% far below other medical procedures. It does matter when people are thinking about the price they pay and incentives to think about that price matter. I think I said something about moral hazard. I'll move along here. So the research indicates that if you have institutions that give people incentives to think about the price instead of having government or a private insurance company paying the bill, this reduces costs. So one study found or studies rather have found that a fully insured population spends about 40 to 50% more than a population with a large deductible. And their status is not measurably improved by the additional services. They're buying a lot of stuff, but it's not doing a whole lot of good. This idea has been recently reaffirmed by a landmark analysis of the Argon experiment. And this is where people were put into a kind of a lottery and the winners of the lottery were given this extended or expanded coverage of medical procedures under Medicaid. And what they found is that they had no significant improvements. The winners of this lottery that had much more of their medical care paid for had no significant improvements in health outcomes in the first two years, despite the fact that they were using more medical care. Often we confuse the use of medical care with improvements in your actual health. And that's not always, they don't always go together. More prescription drugs were used, more office visits, more preventive care, annual spending per individual was in excess of $1,100. And we didn't get very much for that. Technological change, say these authors has indeed increased health care costs in many cases without significantly improving health outcomes. This has occurred because medical insurance in its current state discourages individuals from economizing health care decisions and incentivizes the adoption and overconsumption of services with progressively diminishing returns on investment. Not getting much more, in fact you may be getting less as a whole. In the United States, I used to be able to say most now, just under half of people are getting their medical insurance from their employers. Others are getting their insurance through a federal employer or Medicare Advantage, which is part C of Medicare. And then Medicare and Medicaid account for around a third of medical coverage in the United States. That has expanded recently due to the Affordable Care Act and some other factors. So let's think about this Affordable Care Act. There's been some weakening of it in recent years, but it's still an important part of our medical institutions in the United States. This is sometimes called Obamacare. The main components of this were that insurers had to cover all applicants, regardless of medical history. Premiums were set not based on how likely you were to get sick, but based on your geographic location, which was called a community rating, your age, but not your gender and not based on preexisting conditions. Then there was the mandate. This was one of the more controversial parts of this where everybody had to get medical services or medical insurance except people deemed unable to afford coverage and certain religious groups that had waivers. There were some subsidies available to people who were unable to afford it on their own. If you had an employer with 50 or more employees, then they had to provide coverage for employees who worked more than 30 hours a week. If you didn't get insurance when you were required to or didn't provide it for your employees when you were required to, then you would pay a penalty. That part, the individual penalty for not getting health insurance, has gone away. Health insurance policies were required to cover certain services called essential health benefits, and they couldn't cap benefits over your lifetime. Why would we under the ACA have this rule that says you have to get health insurance? This was intended to combat the problem of adverse selection. If you're required to buy insurance, let's say you're not required to buy insurance, but you're considering insurance and you realize you're a pretty healthy person. Your risks are not very high. Maybe you're young. Maybe you don't have a family history of early onset health problems. You're not likely to require a lot of medical expenses. Then you might say, well, I'm not going to pay because even though I don't like taking risks, it's not worth it to me to pay the health insurance premium. If insurance companies have to ensure everybody, including people who are very expensive, then the other part of this is the insurance company has to be required to cover various conditions, and they can't refuse to cover preexisting conditions. This was to prevent medical insurance companies from cutting back on their coverage in order to meet cost requirements. Insurance, if they have to cover certain expensive conditions, including preexisting conditions, then it would be costly for the insurance company. How do we keep the insurance companies from simply dropping out of the market and not providing insurance at all because they don't want to suffer losses? Well, that's where the subsidies come in. All of this is tied in together. The unintended consequences of this were that premiums went up for the required insurance that you had to buy. People, in spite of the desire of a lot of people to have health insurance, decided they were just going to pay the penalty because even though we don't like paying penalties, it's cheaper than buying the insurance. Insurers began to pull out of the exchanges, limiting their options. Sometimes you had only one option, maybe two in some areas, and then employers began to limit the number of employees. Well, we know that once we hit this number of employees, we're going to have to provide this enormously expensive insurance or pay this punitive tax to the government or fee to the government, so we're just not going to hire that many people. If you were on the edge there, you'd keep your employee numbers down. On average, premiums doubled from the time the ACA went into effect until this was about two years ago. The ACA ended up subsidizing coverage for uninsured Americans by overcharging people who were relatively healthy but were required to buy insurance and then undercharging people who were not so healthy. People did not enroll in these exchanges to the extent that had been expected, understandably, they chose to follow a cheaper option. Now, I said earlier that we sometimes think that if people use more medical services, we're going to get better health because we're thinking too narrowly about what contributes to health. It's not just doctors and hospitals and pharmaceutical products. Medical care itself can be damaging, which is one reason why consuming more medical care might not give you better health. I mentioned that my father was a physician. He said when he graduated from medical school, the speaker at the graduation said, half of what we have taught you is wrong. We just don't know which half. And doctors are doing things today that in 20 years will probably be considered malpractice. Health is also related to many factors apart from medical care. Some of the most health-producing innovations are things like screen wire to prevent insect-borne diseases, canned food, air conditioning, refrigeration. These kinds of things improve health, but they're not related to the medical care industry. If you put more money into medical care, you're taking money away from something else. That something else might have contributed more to your health than medical care itself. So back to the ACA. This is the U.S. age-adjusted mortality rate per 100,000 by year. On the far left, you see about 1998 or 1999. On the far right, we've got 2019. And the full expansion of insurance coverage under the ACA occurred right here. You don't exactly see the age-adjusted mortality rate dropping in response to the ACA. In fact, it seems almost to have plateaued there for several years afterward. So we're not really seeing what was expected or promised in some quarters. It would be helpful to think more about what markets can do for medical care than constantly trying to tweak what government provides in terms of third-party payment or single-payer services, Medicare, and so forth. So in a free market, how would preexisting conditions be handled? This is one of those things where people said, well, of course we want insurance companies to be required to cover preexisting conditions because if not, then you're stuck if you get a disease that you're not going to, you're just going to have to live with the rest of your life and it's going to be very expensive. How do you manage that without going under financially? Well, there are several ways that the free market might be able to handle this. You could insure your insurability. So before you have this condition that's going to be so expensive, you buy insurance against the possibility that you might become an expensive person to insure. Guaranteed renewability. So when I bought life insurance, I bought life insurance that was guaranteed not to change for decades. So even if I developed some disease that was going to kill me before the end of that term, the insurance company is contractually obligated continue to sell me life insurance at that price that I negotiated ahead of time. You could imagine even doing this for your unborn children. You don't know what's going to happen to their health, maybe even early in their life. You could buy that insurance that guarantees their insurability. This is not beyond the range of contracts and then charity, of course, as well. I wish we had time to talk about Medicare for all. Maybe we can do that over launch if you're interested at my table. But we will not do that now. So thank you very much.