My friend Peter Robinson at the Hoover Institute at Stanford was kind enough to pass along a copy of my book The End of Medicine to his colleague, Nobel Laureate and father of free market thinking, Milton Friedman, who sadly passed away yesterday at the age of 94.
From: "Peter Robinson"
----- Original Message -----
From: Milton Friedman
To: Peter Robinson
Sent: Monday, July 17, 2006 10:59 AM
I am delighted to have Andy Kessler's The End of Medicine. I appreciate his suggesting that you send me a copy. But one good turn deserves another. If you will let Gloria know the mailing address for Andy Kessler, she will send him a reprint of my venture into the medical field published in The Public Interest about two years ago.
It goes in a very different direction but it is entirely complementary to Kessler's idea.
A few days later, I received a Xerox copy in the mail of a piece by Milton Friedman titled “How to cure health care”. It is a terrific piece, found here and some of it discusses Gammon’s Law, best summarized by this:
He observed that in "a bureaucratic system . . . increase in expenditure will be matched by fall in production. . . . Such systems will act rather like ‘black holes,’ in the economic universe, simultaneously sucking in resources, and shrinking in terms of ‘emitted production.’"
Trying to have good manners, I fired off a quick thank you note:
To: Milton Friedman
Thank you so much for sending your Winter 2001 Public Interest piece "How to cure health care". I've read it and enjoyed it and realized that it is very complimentary to my book The End of Medicine. MSAs coupled with high deductible catastrophic insurance are inevitable. I am convinced I will never see a penny from Medicare (I'm 47). By the time I am 65, I suspect it will be means tested away from anyone with two nickels to rub together.
My view in The End of Medicine (if you can get through the funny stories) is that Silicon Valley will save the day with ever cheaper technology. It will be these catastrophic/major medical insurers that will insist upon early detection tests, once they are cheaper than chronic care.
I hope you enjoy the book and thank you again for sending your "How to cure health care" piece.
I figured that was that, and was flattered to have had correspondence from such a great thinker. Then an email showed up in my in box one afternoon. How exciting to be told one is wrong in such an elegant way!
To: Andy Kessler
Dear Andy Kessler:
Your book is fascinating and I have learned a great deal from it, but I am also persuaded by it that, ingenious and appealing as is your proposed end of medicine, it is not the way in which the medical problem is going to be solved. What your book illustrates so well is the difference between the kind of market that prevails in ordinary consumer goods such as automobiles, televisions or what-not and that prevailed in medicine until World War II, and the kind of market that now exists in the medical area. The market for automobiles, for TVs and so on is a market in which the producers deal directly with the consumers or, if indirectly, very closely, and in which the producers are incentivized to try to improve the quality and lower the cost of the goods that they are providing. They try to produce items that the consumer wants enough to pay what it costs to produce them.
In medicine today that is not the case. Almost no consumer of medical services pays for his own cost. Almost invariably, a third party pays. The incentives that operate in such a market are very different than the incentives that operate in the consumer market.
Did you ever hear of the Ford Motor Company having employees labeled grant-seekers or grant managers? Your image of spaghetti against the wall is a wonderful image for the kind of market that is described in this book. It is not a market for health at all; it is not a market in which the producer seeks to determine how much consumers are willing to spend on the item it is selling. It is a market for getting financed for fancy scientific work. Only a small part of the money being spent in the industry comes from the consumers of the health services it provides. Most of it is to support the science and the experimentation and the throwing of the spaghetti against the wall.
You cannot tell me that that is an efficient way to generate better health. There are obviously some very able and very serious people in the business, but they are forced to use the procedures appropriate to this kind of market in which the ultimate object, better health, is concealed under a dozen layers of advertising, chicanery and what-not.
To make my point in a different way, let me sketch an analysis of the operation of two kinds of health markets: the one before World War II and the one since then. As it happens, progress in improving health for the total population as measured by expected length of life at birth proceeded at not far from the same rate before World War II and after World War II. But before World War II it was accompanied by spending which never accounted for more than 4 or 5 percent of national income.
After World War II, you had the extraordinary growth in spending so that spending now comes to something like 15 percent of national income. That is what you would expect when you shift from a market in which people are spending their own money for themselves to a market in which they are spending somebody else's money for who knows what.
To be more conjectural, isn't this what you would expect? You have shifted to a far more expensive mode of operation in which the really dramatic results are produced by machines or by drugs and benefit a relatively small fraction of the population. Your plan of early detection is a very good one and goes in the opposite direction. It would benefit
most the great bulk of the population, particularly those who have diseases detected at an early age. It is not going anywhere because there is no pay off. There is no nest of companies or industries that are offering early detection because the money would not come in the main from the patients; it would come from Medicare or Medicaid. So in the
postwar period the greatest progress has been for that group of people who are being paid for by the government. The increase in expected length of life at birth has proceeded at a lower rate after World War II than before; at age 65, at a higher rate. Very sensible and that progress has been very expensive, much more expensive than it was before World
If we could get the market straight so that customers were paying for it, I believe you could achieve at least as great improvements in health at a much lower cost and spread over a wider fraction of the population, but t is not easy to go from one market to the other. The market as it has now developed has very strong special fixed interests who will not give up their special position at all easily. The only real movement in the right direction has been the introduction of health savings accounts and their gradual spread. That may start a slow and steady movement in the right direction but I am not overly optimistic.
In any event thank you for the pleasure and instruction which I got from your book.
Senior Research Fellow
I waited about 5 minutes so as not to appear over eager and then sent this reply:
To: Milton Friedman
Thank you so much for your comments.
First, I’m thrilled you enjoyed the book. That means a lot to me.
Second, I couldn't agree with you more that a real market economy is needed in healthcare and almost none is to be found today (beyond vanity care!). Your "How to cure health care" chapter and the application of Gammons law of bureaucratic displacement makes that point very strongly.
But I wonder if our two views are complimentary.
In other words, if the technology for early detection exists, and because of Silicon Valley, gets cheaper every year, then perhaps that is the stimulus for your free market approach to healthcare. Or vice versa, they go together.
Consumers won't give up their insurance or Medicare because they see the large expense if they do happen to get sick, have a heart attack, cancer, etc. There are two moral hazards that already exist: 1) people smoke or become obese because someone else pays the inevitable hospital bills and 2) once they are sick, they demand almost infinite spending since they are "covered". It is their right, the thinking goes. And the healthcare system is incented to provide as much healthcare as they can, for a fat fee, of course.
We hide the allocation of scarce resources behind phraseology such as “quality adjusted life years” but at the end of the day, it is allocation. We are drifting north towards Canada!
Eventually, this has to reach a "breaking point". It wasn't at 4-5% of national income, as you pointed out, and we still don't seem to be there at 15-16% of GDP we spend today. Perhaps at 20 or 25%, it breaks and then goes one of two ways: 1) Universal nationalized health care, which much more blatantly allocates scarce resources via waiting times a la Canada and the UK
Or 2) the American way, we means test it. In fact, it just started. Medicare just slipped in a 73% surcharge to monthly premiums for those who make over $200,000. Perhaps this is the price umbrella we need. Odd if it’s just a simple progressive tax on the wealthy that ends up turning the whole thing around. Healthcare is one size fits all, there is no price discovery today, hence no real market. This surcharge might be just the thing to kick it off.
Maybe, just maybe, this is how it plays out:
With huge surcharges, the wealthy realize there is no longer value in Medicare. They become more willing to pay for their own healthcare spending, directly or via very high deductible catastrophic insurance and Health Savings Accounts for tax efficiency or tax neutrality.
But, realizing they have to pay more out of pocket, the rich are incented to stay healthy in the first place. As new early detection techniques become affordable for the wealthy directly, it becomes cheaper for them to detect heart, stroke and cancer early than to pay for expensive treatment later. They are probably rich because they already understand how markets and price mechanisms work. The wealthy stay healthy!
And like any good technology, as volume rises, it gets cheaper. Think $2000 cell phones circa 1988 the size of a brick that 100,000 white collar workers bought and now 1 billion $50 phones the size of a deck of cards are sold each year. It democratizes usage over time.
Actually, as you move down the wealth curves to the more cost sensitive middle class, they probably won't be willing to fund their own healthcare unless they see hard evidence that it might actually be cheaper to stay healthy. No one gives up the week in Hawaii for early detection unless you can prove it saves them money. Or some new catastrophic insurance product is invented that demands regular screening in exchange for discount rates. So this takes some time.
But then, the inevitable class warfare kicks in. How dare we have a system that favors the wealthy? As the middle class “opts out” of Medicare because the premiums keep rising, a larger portion of the population enters a market based system with even more incentives for ever cheaper early detection until the technology gets cheap enough to be adopted universally, across the income spectrum. Eventually Blue Cross and Medicare realize it is politically feasible AND cheaper to detect than to pay later, special fixed interests be damned.
OK, maybe a dream, but ever cheaper technology always plays funny tricks with existing “stifled” markets, think mainframe computers, regulated telephony, music retailing, phone based travel agents and on and on. It turned them into market economies when none were thought possible.
So perhaps a market economy (for the wealthy initially) pulls in early detection. Or early detection enables a market economy. The chicken or the egg? Who knows - as long as more chickens are hatched! And all because of a progressive surcharge, won’t that be bizarre.
All the best,
My formal economic training consisted of sleeping through Econ 101 and 20 years of hard knocks on Wall Street. I didn’t expect a reply. But one day, I received this:
To: Andy Kessler
Dear Andy Kessler:
My apologies for being so late in replying to your instructive letter of September 14.
Senior Research Fellow