Disagreement about the role of markets lies at the root of many of our fiercest health care controversies. One side believes that unleashing market forces will rescue our health care system. From this viewpoint, government involvement is inherently destructive, except in rare circumstances. Many opponents of the Affordable Care Act share this opinion.
The other side believes that health care markets are deeply flawed and that government must play a major role in achieving a higher-performing health system. These people point out that markets make no claim to ensuring equity in the use of health care resources, only improved efficiency. Supporters of the ACA tend to hold this view.
Given this fundamental divide, it’s worth considering the conditions underlying the effective functioning of market economies, whether those conditions currently prevail in health care and, if not, what changes would be required to establish them.
Students learn in Economics 101 that several assumptions must hold for free markets to achieve their potential:
- First, consumers and suppliers of goods and services have perfect — or at least sufficient — information. They know or can find out the price and quality of available products.
- Second, consumers and producers are rational. They make reasoned decisions about what to purchase and supply. These decisions maximize their welfare as consumers and their profits as businesses.
- Third, it is easy for producers to enter markets, thus assuring that monopolies don’t form, and that increased competition occurs where prices are excessive, reducing prices to efficient levels.
- Fourth, in any market, there are large numbers of firms selling a homogeneous product.
- Fifth, individual firms cannot affect market prices.
Practically speaking, these conditions rarely exist in pure form anywhere in our economy. In the case of health care, there are a variety of different types of markets. For example, employers purchase insurance, large hospital systems purchase medical supplies, and individuals purchase insurance plans. These markets may embody these conditions to varying degrees, but the most basic health care markets, in which consumers or patients directly buy health care services, depart from this ideal dramatically, as the following examples illustrate.
To begin with, health care consumers not only lack perfect information, but often any information at all. At present, prices in the U.S. health care market are virtually unknowable. Quality data are scant, imperfect, and often confound even experts. Further, medicine is a complex science-based service: even highly trained health professionals struggle to stay current. As a result of social media and the internet, consumers are better informed than ever before, but most depend on advice from health professionals to make informed health care purchases. This kind of imperfect information may help explain why consumers in high-deductible health plans are equally likely to reduce their use of high-value or low-value health care services. They are just as likely to forgo their blood pressure treatments as unnecessary back surgery.
Health care consumers also face unusual challenges to making rational decisions. In medicine there is a saying that any doctor who treats herself has a fool for a patient. Even the most informed individual can have difficulty acting rationally when confronting the emotional turmoil that accompanies their own illness or that of a loved one. Beyond this, there are clear situations where patients’ cognitive abilities are compromised, for example, in cases of stroke, dementia, intoxication, loss of consciousness, delirium, or mental illness.
Competent patients have the inherent right to make their own medical decisions, and many do so wisely and well. But market advocates also must recognize the special obstacles to rational decision-making that face health care consumers.
Consolidation among insurers and health care organizations has radically reduced the number of providers selling health care and health insurance in many U.S. health care markets. Recent work shows that providers in 90 percent of U.S. markets are highly or “super” concentrated.
This consolidation and resulting lack of competition has enabled individual providers to charge excessive prices in many markets. Similarly, government-granted patents create monopolies that enable drug manufacturers to set astounding prices for new drugs and raise them almost at will.
These and other departures from the conditions necessary for effective market functioning suggest the dangers of uncritical reliance on free markets to improve our health care system. At a minimum, advocates of market solutions would be wise to consider three interventions that could increase the probability that markets will function as desired.
- Develop better information on prices and quality. Consumers need information to make informed decisions. Publishing raw data on the prices of care — often referred to as price transparency — is insufficient because it rarely reflects the actual cost consumers face during an episode of care. The price of a chest x-ray that diagnoses pneumonia, for instance, is a poor indicator of the costs of a subsequent hospitalization, not to mention the downstream costs for any previously undetected lung disease. To make health care markets work, advocates must develop approaches to price transparency and quality measurement that are meaningful and understandable to consumers.
- Foster markets for health services that pose the smallest challenges to rational decision-making. Certain health services — often referred to as “shoppable” — involve tests or treatments that are either elective, relatively simple to understand, or nonurgent, which allows patients time to learn and think about them. Examples include screening tests for generally healthy individuals (e.g., colonoscopies, mammograms), elective surgeries (e.g., hip and knee replacement), or necessary but nonemergent care (e.g.,whether to add insulin to a diabetic regimen). Fostering competitive forces in these areas could improve the functioning of the health care market overall. But reformers should be aware that these services are likely to account for a minority of health care activities and, frequently, are not the most expensive ones.
- Promote competition. Unless government finds ways to restore competition among providers where it no longer exists, markets can’t succeed. This is true both for health care services generally and pharmaceuticals in particular.
Given our desperate need for health care reform, the appeal of market solutions is understandable. But it is naïve to assume that they will work in health care just like they do in other sectors. It is time for a frank, open, and nonideological discussion of the problems markets can address in health care and how we can create conditions that will enable markets to function as intended.
HENRY KOTULA 