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Editorials: Point and Counterpoint |

Rebuttal From Drs Gaffney, Verhoef, and Hall FREE TO VIEW

Adam W. Gaffney, MD; Philip A. Verhoef, MD, PhD; Jesse B. Hall, MD, FCCP
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: A. G. has received a National Institutes of Health grant [T32 HL116275]. None declared (P. A. V., J. B. H.).

aDivision of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA

bSection of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL

CORRESPONDENCE TO: Philip A. Verhoef, MD, PhD, Department of Medicine, Section of Pulmonary and Critical Care, 5841 S Maryland Ave, MC 6076, University of Chicago, Chicago, IL 60637


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(1):14-15. doi:10.1016/j.chest.2016.02.661
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We welcome this important debate, which is unfolding at a critical political juncture. Dr Berdine’s counterpoint has usefully broadened our discussion beyond the issue of single payer to the larger question of the role of the free market in health care.

Dr Berdine argues that in an unhindered competitive health-care marketplace, the market will clear at a price and quantity of goods/services that, as if by definition, leaves all parties maximally satisfied. This argument is little more than a tautology that would, if possible, result in a health-care dystopia that society would not accept. Low-income individuals might “choose” to spend their money on food instead of asthma inhalers. By Dr Berdine’s logic, this scenario is as it should be, and any intervention by government would only make things worse. Those dying of status asthmaticus might beg to differ, if they were able, as might patients with hypertension who suffer strokes because they elected to cover their rent instead of paying for physician visits.

He argues that government involvement in the health care realm has “priced health care beyond the reach of the average person.” It is a rather curious point, because the United States already has a relatively privatized and unregulated health-care system (compared with other high-income nations) while also having the highest costs. Furthermore, $375 billion of our expenditures can be attributed to wasteful administrative costs associated with our multipayer insurance market.

Dr Berdine does make a good point when he notes that government-granted patent monopolies can result in high drug prices. To address this issue, a single-payer national health program would directly negotiate with pharmaceutical companies over drug prices. Indeed, the Veterans Health Administration pays 40% less for prescription drugs compared with Medicare, indicating that substantial cost-savings could be achieved by facilitating such negotiations.

A free market for health care is not only undesirable: it is, as economists have noted for decades, a fantasy. Fundamentally, the degree of information asymmetry between the buyer (the patient) and the seller (the provider) prevents health care from conforming to the theoretical tenets of free-market economics. Kenneth Arrow famously contended that the uncertainty intrinsic to health care makes it unique from other goods and services. The health economist Bob Evans has argued that not only has there never been a pure free market in health care but that “inherent characteristics of health and health care make it impossible that there ever could be.” On the contrary, he argues, attempts to inject market mechanisms into health care are fundamentally about redistribution. As health-care costs are shifted from public to out-of-pocket sources, those with higher incomes invariably benefit.

The US divergence from other high-income nations is a disaster. We contend with uninsurance and underinsurance, a lack of coverage for critical benefits, worse outcomes, and higher overall costs. As others have noted, the savings made possible through a single-payer system would allow extension of health care as a social right to the entire nation. In contradistinction with a fantastical health-care free market, such a program is both attainable and desirable.

References

Berdine G.G. . Counterpoint: Should pulmonary/ICU physicians support single-payer health-care reform? No. Chest. 2016;150:11-14 [PubMed]journal
 
Rice T. .Unruh L.Y. .Rosenau P. .Barnes A.J. .Saltman R.B. .van Ginneken E. . Challenges facing the United States of America in implementing universal coverage. Bull World Health Organ. 2014;92:894-902 [PubMed]journal. [CrossRef] [PubMed]
 
Jiwani A. .Himmelstein D. .Woolhandler S. .Kahn J.G. . Billing and insurance-related administrative costs in United States' health care: synthesis of micro-costing evidence. BMC Health Serv Res. 2014;14:556- [PubMed]journal. [CrossRef] [PubMed]
 
Frakt A.B. .Pizer S.D. .Feldman R. . Should Medicare adopt the Veterans Health Administration formulary? Health Econ. 2012;21:485-495 [PubMed]journal. [CrossRef] [PubMed]
 
Arrow K.J. . Uncertainty and the welfare economics of medical care. Am Econ Rev. 1963;53:941-973 [PubMed]journal
 
Evans R.G. . Going for the gold: the redistributive agenda behind market-based health care reform. J Health Polit Policy Law. 1997;22:427-465 [PubMed]journal. [CrossRef] [PubMed]
 
Woolhandler S. .Himmelstein D.U. .Angell M. .Young Q.D. . Physicians' Working Group for Single-Payer National Health Insurance. Proposal of the Physicians' Working Group for Single-Payer National Health Insurance. JAMA. 2003;290:798-805 [PubMed]journal. [CrossRef] [PubMed]
 

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Tables

References

Berdine G.G. . Counterpoint: Should pulmonary/ICU physicians support single-payer health-care reform? No. Chest. 2016;150:11-14 [PubMed]journal
 
Rice T. .Unruh L.Y. .Rosenau P. .Barnes A.J. .Saltman R.B. .van Ginneken E. . Challenges facing the United States of America in implementing universal coverage. Bull World Health Organ. 2014;92:894-902 [PubMed]journal. [CrossRef] [PubMed]
 
Jiwani A. .Himmelstein D. .Woolhandler S. .Kahn J.G. . Billing and insurance-related administrative costs in United States' health care: synthesis of micro-costing evidence. BMC Health Serv Res. 2014;14:556- [PubMed]journal. [CrossRef] [PubMed]
 
Frakt A.B. .Pizer S.D. .Feldman R. . Should Medicare adopt the Veterans Health Administration formulary? Health Econ. 2012;21:485-495 [PubMed]journal. [CrossRef] [PubMed]
 
Arrow K.J. . Uncertainty and the welfare economics of medical care. Am Econ Rev. 1963;53:941-973 [PubMed]journal
 
Evans R.G. . Going for the gold: the redistributive agenda behind market-based health care reform. J Health Polit Policy Law. 1997;22:427-465 [PubMed]journal. [CrossRef] [PubMed]
 
Woolhandler S. .Himmelstein D.U. .Angell M. .Young Q.D. . Physicians' Working Group for Single-Payer National Health Insurance. Proposal of the Physicians' Working Group for Single-Payer National Health Insurance. JAMA. 2003;290:798-805 [PubMed]journal. [CrossRef] [PubMed]
 
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