With Health Care, First Fix Terms of Engagement

In the coming weeks, President Bush intends to initiate a long-overdue national debate on what do about health care. The sector represents 16 percent of the economy and is growing twice as fast as the incomes of the people who pay for it. Even at that level of spending, however, 40 million Americans have no health insurance at all, while the health of those who do is worse than in many other industrialized countries where spending is considerably lower. If we don't fix it, the health care "system" will render U.S. businesses uncompetitive, require huge increases in taxes and eventually bankrupt the country.

In other words, it's important to get it right this time, and a president nearing the end of his second term who is willing and able to take on the special interests is just the person to lead it. Unfortunately, by framing the debate as an ideological choice between individual control and more government, Bush is setting himself up for another Social Security-like failure.

The White House line that we need to get government out of the health care business, or that we'd have better, cheaper health care from an unregulated market, is not only nonsense. It is also the kind of ideologically charged rhetoric that will immediately ensure that Democrats oppose anything that follows it.

Government -- in the form of Medicare, Medicaid and insurance coverage for employees and veterans -- already pays half of the nation's health bill. Those are among the most popular government programs, cherished by Republicans and Democrats alike. So to think government won't be heavily involved in health care is an economic and political fantasy.

Moreover, we know that by its nature, health care is a highly imperfect market.

It suffers from tremendous "information asymmetries" between sellers (doctors, hospitals and insurers) and buyers (patients).

It is rife with what economists call "principal-agent problems" -- like the doctor who benefits financially by providing more medical treatment than patients need, or health insurers that are always trying to get them to consume less.

In rural areas, there are often few providers and little or no competition.

And left alone, insurance markets will tend to lower costs for the young and healthy and raise them for the sick and aged -- an outcome that is as socially unacceptable as it is economically efficient.

We know from behavioral economics that people are particularly irrational about health care risks, with a tendency to overconsume, overpay and over-insure.

Moreover, threats like that posed by the Asian bird flu remind us that public health is a public good in which private markets reliably underinvest.

So, please, let's dispense with the free market, personal choice rhetoric. Economically, its inappropriate. Politically, its just stupid. It didn't work with Social Security and -- trust me on this one -- it really won't work with health care.