Truth on the Market

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Archive for the ‘regulation’ Category

New Technology in Europe

Posted by Paul H. Rubin on May 21, 2012

Last week the New York Times ran an article, “Building the Next Facebook a Tough Task in Europe“, by Eric Pfanner, discussing the lack of major high tech innovation in Europe.  Eric Pfanner discusses the importance of such investment, and then speculates on the reason for the lack of such innovation.  The ultimate conclusion is that there is a lack of venture capital in Europe for various cultural and historical reasons.  This explanation of course makes no sense.  Capital is geographically mobile and if European tech start ups were a profitable investment that Europeans were afraid to bankroll, American investors would be on the next plane.

Here is a better explanation.  In the name of “privacy,” the EU greatly restricts the use of consumer online  information.  Josh Lerner has a recent paper, “The Impact of Privacy Policy Changes on Venture Capital Investment in Online Advertising Companies” (based in part on the work of Avi Goldfarb and Catherine E. Tucker, “Privacy Regulation and Online Advertising“) finding that this restriction on the use of information is a large part of the explanation for the lack of tech investment in Europe.  Tom Lenard and I have written extensively about the costs of privacy regulation (for example, here) and this is just another example of these costs, although the costs are much greater in Europe than they are here (so far.)

Posted in advertising, consumer protection, intellectual property, privacy, regulation, technology | Leave a Comment »

Richard Thaler on “Slippery Slopes”

Posted by Paul H. Rubin on May 13, 2012

In today’s New York Times, Richard Thaler argues that the Constitutional “slippery slope” argument in the Obamacare case (“Today health care, tomorrow broccoli”) is misguided.  This is a strange argument in this particular case.  We must remember that all of today’s commerce clause jurisprudence (which everyone agrees has greatly expanded the power of the Federal government to regulate economic activity) rests on Wickard v. Filburn, a 1942 case involving a small wheat and chicken farmer in Ohio.  If ever there was a slippery slope, this is it, and it seems rational to fear another in the same Constitutional line.

Posted in commerce clause, constitutional law, health care, health care reform debate, law and economics | 1 Comment »

Taxing Regulatory Failure

Posted by Michael Sykuta on May 7, 2012

Last month, the IRS and the US Treasury Department issued proposed rules to implement a new tax on health insurance providers and self-insured groups. The tax is part of the Patient Protection and Affordable Care Act (ACA) and will be used to help fund the new Patient-Centered Outcomes Research Institute (PCORI), which will conduct research evaluating and comparing health outcomes and the clinical effectiveness, risks and benefits of medical treatments. The proposed “comparative effectiveness research fee” will cost insurers $1 for every covered person (including dependents) in the first year and $2 in the following 6 years. The fee is scheduled to end by 2019.

Sounds reasonable on the surface. If the government is going to regulate health care, it makes sense that it would want to do research on what procedures are more or less effective so it can determine what procedures should or should not be covered under different circumstances. If that sounds a bit like rationing, it is. But it would be based on some standard of productivity. However, reasonable on the surface does not reasonable on the whole make.

One unanswered question is why the government needs to create an entire new federal agency to conduct comparative effectiveness research. One would think that private health insurance companies would already have an incentive to determine what procedures are most effective. This is also the kind of work that medical researchers engage in all the time (a quick Google Scholar search results in almost a half-million articles on “comparative effectiveness of medical treatment“). So it is quite likely that the federal government is simply recreating the wheel–a very expensive wheel–while adding costs to insurance providers. And when insurance providers’ costs go up, so do prices for healthcare coverage.

Of course, it is possible that the private insurance market is not currently doing this kind of research on comparative effectiveness of treatments and is ignoring the plethora of research in the medical journals. But if having that information could help those companies increase their profits by allowing them to direct patients to more effective treatments that reduce cost of coverage, why would they not use it?  If companies are not using this kind of information, there must be no economic incentive to do so. Which begs the question: why not?

A possible explanation is that the market for health insurance coverage has been protected from competitive pressures by the nature of the regulatory system. Although the market for insurance may seem like a national market, a maze of state-level regulations reduce the effective size of markets and increase the overall costs to insurance providers. Different regulatory processes and standards across states make it more difficult for insurance companies to operate across many states. This reduces competitive pressures between insurance providers. However, it doesn’t seem like a sufficient argument to support the idea that insurance companies regularly ignore information that would allow them to increase their profits, even if they were not competing as vigorously on prices.

Besides the motivation question, there is also a question of what the possible consequences of the new PCORI’s comparative research may be. At a minimum, one would expect that the government would begin dictating what procedures can or cannot be covered by federally-approved health care plans. While such a determination by an individual insurance company may lead to competitive behavior between providers offering different coverages, federally-established mandates will further reduce competition by limiting the margins (coverage options) on which insurers can compete.

It is also reasonable to suppose that a federally-approved list of  procedures will reduce the likelihood of innovation in treatment methods and practices by medical professionals. Reducing incentives to innovate will slow advances (and potential cost reductions) associated with possible new treatments. Having to get federal approval for new treatment options will do for treatments what the FDA has done for introduction of new pharmaceuticals (increasing costs, reducing the number of alternatives that reach clinical trials, and slowing the time to market).

The PCORI is mandated as part of the ACA. The ACA itself is a monstrosity of regulations to correct regulatory failures (part of the economic argument around the controversial mandate provisions now being reviewed by the US Supreme Court). The PCORI tax is just one more element of a regulatory response to regulation-induced market failures that is as likely to reduce health care options as to provide them.

Posted in health care, health care reform debate, markets, regulation, Sykuta | Leave a Comment »

Gary Becker, the Economic Approach to Crime, and Guerilla Grafters

Posted by Josh Wright on April 8, 2012

Fruit trees in a number of cities, including San Francisco, are prevented from bearing fruit in the name of “protecting” pedestrians from slip and falls and keeping away insects and vermin.  In response to these regulations, a group of Guerilla Grafters has emerged to — you guessed it — graft fruit bearing branches onto the non-fruit bearing city trees.

But grafting trees to bear the occasional pear is not all fun and games, apparently.  San Francisco officials consider the renegade arborists to be engaged in a serious offense (San Francisco Examiner):

While the grafters’ activities might seem harmless, Public Works Director Mohammed Nuru said the renegade gardeners are running afoul of the law.

“The trees that are in the right of way, they’re not for grafting,” he said. “The City considers such vandalism a serious offense. There would be fines for damage to city property.”

Nuru had not heard of Guerrilla Grafters, but said he would ask his staff to investigate. Meanwhile, he added, if the grafters have ideas about urban agriculture, they should discuss them with city officials.

NPR embeds one reporter with grafter Tara Hui on a covert grafting operation.  The first thought that crossed my mind as I read the story was skepticism that the costs associated with fallen fruit on city trees could be significant.  The second was hope the story had overestimated the prevalence of this type of regulation.  There is also some interesting law and economics.  The cops and robbers angle in the NPR story with Hui attempting to avoid detection for fear of sanction by the city authorities in the way of fines for vandalism was also interesting.  From the standard Beckerian model of rational criminal behavior we see Hui’s sensitivity to changes in the “price” of engaging in guerilla grafting (that is, the probability of detection weighted by the sanction she will pay if caught) and investments to avoid detection.

But what about the economic benefits?  Here’s Hui’s account:

“If we say where it is, they could come after me,” says Tara Hui, a fruit tree grafter. She’s talking about city officials, who manage the trees and say it’s illegal to have fruit trees on sidewalks.  So let’s just say we’re in some Bay Area city in a working-class neighborhood, at a line of pear trees that bear no pears.

Hui and two assistants pull out a knife, reach into a plastic bag filled with twigs no bigger than your pinkie, and cut from a fruit bearing pear tree. She says it’s an Asian pear, and that she’s grafting it onto a flowering pear tree.  They whittle a wedge into one end of their twig, then cut a groove into a similar-sized twig on the city tree. They join the two, like tongue and groove carpenters. And when their grafted twig eventually grows into a branch.

“There will be a much better looking tree that actually will provide fruit for people that come by,” Hui says.

Hui’s motives to break the law are straightforward.

“We don’t have a supermarket and we have very few produce stores [here],” she says. “What better to alleviate scarcity of healthy produce in an impoverished area than to grow them yourself and to have it available for free.”

For a recent and illuminating paper on the law and economics of criminal behavior which attempts to incorporate conventional critiques of the economic approach — for example, that criminals lack self-control, have non-standard preferences or do not act in their own self-interest — into the standard model, see Murat Mungan’s Law and Economics of Fluctuating Criminal Tendencies.  Mungan’s main goal is to show that the standard economic approach is capable of modification so as to absorb more realistic assumptions and that it gains explanatory power by doing so.

HT goes to Steve Salop for pointing me to the Guerilla Grafter story.

Posted in behavioral economics, economics, regulation | 3 Comments »

My Professor, My Judge, and the Doctrine of Judicial Review

Posted by Thom Lambert on April 3, 2012

Imagine if you picked up your morning paper to read that one of your astronomy professors had publicly questioned whether the earth, in fact, revolves around the sun.  Or suppose that one of your economics professors was quoted as saying that consumers would purchase more gasoline if the price would simply rise.  Or maybe your high school math teacher was publicly insisting that 2 + 2 = 5.  You’d be a little embarrassed, right?  You’d worry that your colleagues and friends might begin to question your astronomical, economic, or mathematical literacy.

Now you know how I felt this morning when I read in the Wall Street Journal that my own constitutional law professor had stated that it would be “an unprecedented, extraordinary step” for the Supreme Court to “overturn[] a law [i.e., the Affordable Care Act] that was passed by a strong majority of a democratically elected Congress.”  Putting aside the “strong majority” nonsense (the deeply unpopular Affordable Care Act got through the Senate with the minimum number of votes needed to survive a filibuster and passed 219-212 in the House), saying that it would be “unprecedented” and “extraordinary” for the Supreme Court to strike down a law that violates the Constitution is like saying that Kansas City is the capital of Kansas.  Thus, a Wall Street Journal editorial queried this about the President who “famously taught constitutional law at the University of Chicago”:  “[D]id he somehow not teach the historic case of Marbury v. Madison?”

I actually know the answer to that question.  It’s no (well, technically yes…he didn’t).  President Obama taught “Con Law III” at Chicago.  Judicial review, federalism, the separation of powers — the old “structural Constitution” stuff — is covered in “Con Law I” (or at least it was when I was a student).  Con Law III covers the Fourteenth Amendment.  (Oddly enough, Prof. Obama didn’t seem too concerned about “an unelected group of people” overturning a “duly constituted and passed law” when we were discussing all those famous Fourteenth Amendment cases – Roe v. Wade, Griswold v. Connecticut, Romer v. Evans, etc.)  Of course, even a Con Law professor focusing on the Bill of Rights should know that the principle of judicial review has been alive and well since 1803, so I still feel like my educational credentials have been tarnished a bit by the President’s “unprecedented, extraordinary” remarks.

Fortunately, another bit of my educational background somewhat mitigates the reputational damage inflicted by the President’s unfortunate comments.  This morning, the judge for whom I clerked, Judge Jerry E. Smith of the U.S. Court of Appeals for the Fifth Circuit, called the President’s bluff.

Here’s a bit of transcript from this morning’s oral argument in Physicians Hospital of America v. Sebelius, a case involving a challenge to the Affordable Care Act:

Judge Jerry E. Smith: Does the Department of Justice recognize that federal courts have the authority in appropriate circumstances to strike federal statutes because of one or more constitutional infirmities?

Dana Lydia Kaersvang (DOJ Attorney): Yes, your honor. Of course, there would need to be a severability analysis, but yes.

Smith: I’m referring to statements by the President in the past few days to the effect…that it is somehow inappropriate for what he termed “unelected” judges to strike acts of Congress that have enjoyed – he was referring, of course, to Obamacare – what he termed broad consensus in majorities in both houses of Congress.

That has troubled a number of people who have read it as somehow a challenge to the federal courts or to their authority or to the appropriateness of the concept of judicial review. And that’s not a small matter. So I want to be sure that you’re telling us that the attorney general and the Department of Justice do recognize the authority of the federal courts through unelected judges to strike acts of Congress or portions thereof in appropriate cases.

KaersvangMarbury v. Madison is the law, your honor, but it would not make sense in this circumstance to strike down this statute, because there’s no –

Smith: I would like to have from you by noon on Thursday…a letter stating what is the position of the Attorney General and the Department of Justice, in regard to the recent statements by the President, stating specifically and in detail in reference to those statements what the authority is of the federal courts in this regard in terms of judicial review. That letter needs to be at least three pages single spaced, no less, and it needs to be specific. It needs to make specific reference to the President’s statements and again to the position of the Attorney General and the Department of Justice.

I must say, I’m pretty dang proud of Judge Smith right now.  And I’m really looking forward to reading that three-page, single-spaced letter.

Posted in commerce clause, constitutional law, health care, health care reform debate, musings, politics | 167 Comments »

Potential Problems with an FDA Model for Regulating Financial Products

Posted by Thom Lambert on April 2, 2012

New York Times columnist Gretchen Morgenson is arguing for a “pre-clearance”  approach to regulating new financial products:

The Food and Drug Administration vets new drugs before they reach the market. But imagine if there were a Wall Street version of the F.D.A. – an agency that examined new financial instruments and ensured that they were safe and benefited society, not just bankers.  How different our economy might look today, given the damage done by complex instruments during the financial crisis.

The idea Morgenson is advocating was set forth by law professor Eric Posner (one of my former profs) and economist E. Glen Weyl in this paper.  According to Morgenson,

[Posner and Weyl] contend that new instruments should be approved by a “financial products agency” that would test them for social utility. Ideally, products deemed too costly to society over all – those that serve only to increase speculation, for example – would be rejected, the two professors say.

While I have not yet read the paper, I have some concerns about the proposal, at least as described by Morgenson.

First, there’s the knowledge problem.  Even if we assume that agents of a new “Financial Products Administration” (FPA) would be completely “other-regarding” (altruistic) in performing their duties, how are they to know whether a proposed financial instrument is, on balance, beneficial or detrimental to society?  Morgenson suggests that “financial instruments could be judged by whether they help people hedge risks – which is generally beneficial — or whether they simply allow gambling, which can be costly.”  But it’s certainly not the case that speculative (“gambling”) investments produce no social value.  They generate a tremendous amount of information because they reflect the expectations of hundreds, thousands, or millions of investors who are placing bets with their own money.  Even the much-maligned credit default swaps, instruments Morgenson and the paper authors suggest “have added little to society,” provide a great deal of information about the creditworthiness of insureds.  How is a regulator in the FPA to know whether the benefits a particular financial instrument creates justify its risks? 

When regulators have engaged in merits review of investment instruments — something the federal securities laws generally eschew — they’ve often screwed up.  State securities regulators in Massachusetts, for example, once banned sales of Apple’s IPO shares, claiming that the stock was priced too high.  Oops.

In addition to the knowledge problem, the proposed FPA would be subject to the same institutional maladies as its model, the FDA.  The fact is, individuals do not cease to be rational, self-interest maximizers when they step into the public arena.  Like their counterparts in the FDA, FPA officials will take into account the personal consequences of their decisions to grant or withhold approvals of new products.  They will know that if they approve a financial product that injures some investors, they’ll likely be blamed in the press, hauled before Congress, etc.  By contrast, if they withhold approval of a financial product that would be, on balance, socially beneficial, their improvident decision will attract little attention.  In short, they will share with their counterparts in the FDA a bias toward disapproval of novel products.

In highlighting these two concerns, I’m emphasizing a point I’ve made repeatedly on TOTM:  A defect in private ordering is not a sufficient condition for a regulatory fix.  One must always ask whether the proposed regulatory regime will actually leave the world a better place.  As the Austrians taught us, we can’t assume the regulators will have the information (and information-processing abilities) required to improve upon private ordering.  As Public Choice theorists taught us, we can’t assume that even perfectly informed (but still self-interested) regulators will make socially optimal decisions.  In light of Austrian and Public Choice insights, the Posner & Weyl proposal — at least as described by Morgenson — strikes me as problematic.  [An additional concern is that the proposed pre-clearance regime might just send financial activity offshore.  To their credit, the authors acknowledge and address that concern.]

Posted in economics, financial regulation, Hayek, Knowledge Problem, law and economics, regulation | 4 Comments »

The Best Way to Save Endangered Antelope: Allow Hunting on Private Preserves

Posted by Thom Lambert on March 31, 2012

There’s some good news on the endangered species front:  Three species of endangered African antelopes — the Scimitar-Horned Oryx, Addax, and Dama Gazelle — are coming back with a vengeance.  At least in Texas, where the population of the three antelope species quadrupled from 2004 to 2010, growing to a combined total of around 17,000.

What’s the secret?  Private property rights and markets.  In 2005, the U.S. Fish and Wildlife Service (FWS), which administers the Endangered Species Act (ESA), created a blanket exception from the ESA’s “taking” prohibition for captive-bred U.S. antelope.  FWS recognized that the rare African antelopes have great value to trophy hunters and, accordingly, to ranchers who are able set aside ideal habitat for the creatures.  The prospect of hefty bounties — up to $10,000 per antelope — has encouraged the formation of private preserves, much to the benefit of the three endangered species.

Unfortunately, an environmental organization operating under the misnomer “Friends of Animals” sued to stop hunting of the antelopes on private preserves.  “Hunting these antelope is no way to save them or treat them with dignity,” proclaimed the Friends of Animals vice-president (apparently ignoring the data on the antelopes’ population explosion in Texas). 

Today’s WSJ reports that Friends of Animals has procured new rules that will require exotic ranchers to obtain costly individual take permits for every instance of hunting.  Faced with the prospect of having to navigate the costly and time-consuming permit process, many exotic ranchers are considering whether to abandon their antelope operations altogether.  If they do so, we can expect the worldwide population of these antelope species to dwindle.  Yet another consequence of our perverse Endangered Species Act, which renders listed species a liability to landowners (thereby encouraging a “shoot, shovel, and shut up” strategy) and fights all efforts to encourage market-based conservation efforts.

Posted in environment, markets, regulation | 2 Comments »

David Schleicher on City Unplanning

Posted by Josh Wright on March 7, 2012

Forbes interviews my colleague and office neighbor David Schleicher on his new and very interesting paper, City Unplanning.  This paper continues Schleicher’s interesting line of research on the law and economics of cities with a creative and powerful analysis of the political economy of zoning in big cites.

Here’s a brief snippet from the start of the interview:

For starters, how about a brief rundown of your story of why housing in major cities is so expensive.

Generations of scholars assumed that, while exclusive suburbs use zoning rules to limit development to keep people out and to increase the average value of housing, big cities don’t do that kind of thing because they are run by “growth machines” or ever more powerful coalitions of developers and the politicians who love them.

But in fact for most of the Twentieth Century, when urban housing prices went up, people starting building housing and prices went down. But, at some point, this broke down.

In a number of big cities, new housing starts seem uncorrelated or only weakly correlated with housing prices and the result of increasing demand while holding supply steady is that price went up fast. The average cost of a Manhattan apartment is now over $1.4 million and the average monthly rent is over $3,300.

The only explanation is that zoning rules stop supply from increasing in the face of rising demand. (In case you are wondering, this not a bubble phenomenon—this happened in many cities before the housing bubble, and the behavior of housing markets during and after the crisis is completely consistent with a story about big city housing supply constraints.)  And it’s not like real estate developers suddenly became political weaklings. What gives?

The key to my story is that urban legislatures don’t have competitive local parties—we don’t see big city legislatures divided between Republicans and Democrats, each trying to create a localized brand for competence on local issues. Instead, most local legislatures are either non-partisan or dominated by one party.

As a result, there is no one with the power and incentives to strike deals between legislators in order to promote things that are good for people across the city. And there is no one to decide the order in which issues are decides, which matters when legislative preferences “cycle,” or there are majorities that prefer a to b, b to c, and c to a.

The result of the lack of competitive local parties is that procedural rules matter a lot—they set the voting order, which can determine the outcome.

Part II of the interview is available here.  The abstract is here:

Generations of scholarship on the political economy of zoning have tried to explain a world in which tony suburbs run by effective homeowner lobbies use zoning to keep out development, but big cities allow relatively untrammeled growth because of the political influence of developers. Further, this literature has assumed that, while zoning restrictions can cause “micro-misallocations” inside a metropolitan region, they cannot increase housing prices throughout a region because some of the many local governments in a region will allow development. But these theories have been overtaken by events. Over the past few decades, land use restrictions have driven up housing prices in the nation’s richest and most productive regions, resulting in massive changes in where in America people live and reducing the growth rate of the economy. Further, as demand to live in them has increased, many of the nation’s biggest cities have become responsible for substantial limits on development. Although developers are, in fact, among the most important players in city politics, we have not seen enough growth in the housing supply in many cities to keep prices from skyrocketing.

This paper seeks to explain these changes with a story about big city land use that places the legal regime governing land use decisions at its center. Using the tools of positive political theory, I argue that, in the absence of strong local political parties, land use law sets the voting order in local legislatures, determining policy from potentially cycling preferences. Specifically, these laws create a peculiar procedure, a form of seriatim decision-making in which the intense preferences of local residents opposed to re-zonings are privileged against more weakly-held citywide preferences for an increased housing supply. Without a party leadership to organize deals and whip votes, legislatures cannot easily make deals for generally-beneficial legislation stick. Legislators, who may have preferences for building everywhere to not building anywhere, but stronger preferences for stopping construction in their districts, “defect” as a matter of course and building is restricted everywhere. Further, the seriatim nature of local land use procedure results in a large number of “downzonings,” or reductions in the ability of landowners to build “as of right”, as big developers do not have an incentive to fight these changes. The cost of moving amendments through the land use process means that small developers cannot overcome the burdens imposed by downzonings, thus limiting incremental growth in the housing stock.

Finally, the paper argues that, as land use procedure is the problem, procedural reform may provide a solution. Land use and international trade have similarly situated interest groups. Trade policy was radically changed, from a highly protectionist regime to a largely free trade one, by the introduction of procedural reforms like the Reciprocal Trade Agreements Act, adjustment assistance, and “safeguards” measures. The paper proposes changes to land use procedures that mimic these reforms. These changes would structure voting order and deal-making in local legislatures in a way that would create support for increases in the urban housing supply.

Posted in economics, legal scholarship, regulation, scholarship, zoning | Comments Off

Federalist Society Event (March 14): Antitrust as Regulation?

Posted by Josh Wright on March 6, 2012

You can register here.  From the website description:

The popular press is full of reports of a renewed vigor in parts of our antitrust enforcement regime that address the conduct of leading firms. Investigations have been started or rumored against any number of firms near or at the top of various parts of the technology sector, including Intel, Yahoo, Google, Apple, AT&T, IBM, Facebook, and others. Forbes reported that the number of antitrust cases filed by the Department of Justice rose by 50 percent in 2011. These suits can be costly to defend, and carry large potential fines. Consent decrees negotiated to end such litigation often provide detailed terms and conditions governing the manner in which industry players may and may not conduct business going forward. In this environment, has antitrust enforcement itself become a regulatory mechanism? If so, does it represent the best way to regulate dynamic industries? These and other questions will be addressed by our panel of experts.

Confirmed Speakers to Date:

  • Hon. Ronald A. Cass, Cass & Associates, PC 
  • Hon. James C. Miller III, Husch Blackwell, LLP, and former Director of the U.S. Office of Management & Budget 
  • Hon. Charles F. “Rick” Rule, Cadwalader, Wickersham & Taft LLP 
  • Mr. Robert A. Skitol, Drinker Biddle & Reath LLP

Date: Wednesday, March 14, 2012

Time:12:00 noon – 2:00 p.m.

Location: National Press Club

529 14th St. NW, 13th Floor
Washington, D.C. 20045

Posted in antitrust, regulation, technology | Comments Off

Is Dental Care a Preventive Measure Health Insurers Must Cover? Let’s Hope Not.

Posted by Thom Lambert on March 1, 2012

I recently heard an ominous NPR story on the rise in trips to the emergency room by people seeking dental treatment.  In 2009 alone, Tennessee’s emergency rooms had more than 55,000 dental-related visits — five times as many as for burns.  Florida’s emergency rooms experienced over 115,000 ER visits for dental matters in 2010.  Charges for those visits totaled $88 million.

This is a big problem.  Emergency rooms aren’t set up to treat dental patients, and the charges they impose dwarf those dentists charge for emergency work, much less for the sort of routine dental service that prevents dental emergencies in the first place.  A huge amount of money could be saved if people — especially the poor folks who tend to use the emergency room for dental work — would just go to the dentist.

One approach to the problem would be to try to reduce the cost of preventive dental care.  The vast majority of routine dental care can be (and, it seems from my own experience, usually is) provided by technicians who have some relatively low-cost specialized training but are not licensed dentists who have earned an expensive degree from a dental school.  If regulators gave these folks more leeway to provide routine services without having to send their bills through a dentist who is sure to mark them up, the price of routine preventive services would fall, and more low-income folks would purchase them.  The dental lobby, however, fights tooth and nail against this sort of reform.

A more likely policy response may come under the Affordable Care Act (aka Obamacare).  As we’ve recently seen in the brouhaha over the Obama Administration’s contraception mandate, the Affordable Care Act requires that insurers fully cover, without any copayment requirement, any preventive measures that the United States Preventive Services Task Force (USPSTF) has rated “A” or “B” in terms cost-effectiveness.  Birth control and the so-called “morning after” pill were so rated, which is why the Obama Adminstration is requiring that employer-provided insurance policies cover them.

Isn’t basic dental service (routine cleanings, check-ups, etc.) a cost-effective preventive measure?  It certainly prevents serious and costly disease.  According to the USPTF’s grade definitions, a preventive measure will receive an A or B rating if there is at least a “moderate certainty that the net benefit is moderate to substantial.”  The NPR report and the Pew Study on which it’s based suggest that routine dental services would surely earn an A or B rating.  If they’re so designated by USPTF, then it would seem that employer-provided insurance policies would have to cover them.  [Note that I use the awkward "it would seem" phrase because I haven't scoured the gazillion-page statute to see if there's some sort of exemption that would except dental services; there may well be.]   

“So what?”, you ask.  Why would it be a bad thing if health insurance routinely covered dental procedures that would prevent serious ailments down the road?  More people would then take the cost-effective precautions, thereby reducing the overall cost of health care.

Perhaps.  But greatly expanding insurance coverage of dental services would likely have an unintended (except from the dentists’ perspective!) consequence:  It would drive up the price of dentistry.  In the current environment in which most people lack dental insurance or have relatively stingy policies, consumers are intensely interested in the price of dental services.  Dentists respond by competing on price or, what is the same thing, the provision of “free” services like teeth whitening for new customers.  Cheapos like me just go to a different dentist for every routine cleaning in order to get a new customer discount each time.

If employer-provided health insurance begins to cover the full price of routine dental services — an outcome that would seem to be required by the Affordable Care Act — then we can expect these promotions to end.  Why would dentists compete on price when the customers selecting the dentists have no skin in the game?  Insurers might inject some price competition by setting maximum prices for “in network” dentists, but price competition at this level is far less vigorous than when the consumer is directly paying her own money out of pocket.  (Compare, e.g., price competition over LASIK treatments, purchased out of pocket, to price competition for routine doctor visits, which insurance covers in large part.) 

As economist after economist after economist explained in the debate over the Affordable Care Act, a primary reason for spiraling health care costs is the prevalence of generous third-party insurance that covers almost everything and thereby decimates patients’ incentive to shop on – and thus providers’ incentive to compete on — price.  Expanding this pernicious dynamic into the realm of dental services would be disastrous for all except dentists.

A far better way to address the problem of underutilization of preventive dental services would be to lower the cost of those services by liberalizing dentistry regulation (i.e., allowing trained non-dentists, who are cheaper, to do more).  The dental lobby will oppose such a move, and the Affordable Care Act, I fear, provides it with an alternative policy to endorse and pursue.  Yet another example of how the Affordable Care Act’s effort to increase insurance coverage undermines efforts to reduce costs.

Posted in economics, health care reform debate, law and economics, licensing, regulation | 2 Comments »

 
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