注册 登录  
 加关注
   显示下一条  |  关闭
温馨提示!由于新浪微博认证机制调整,您的新浪微博帐号绑定已过期,请重新绑定!立即重新绑定新浪微博》  |  关闭

TheMoneyIllusion货币幻觉

美国本特利大学经济学教授斯科特·萨姆纳(Scott Sumner)

 
 
 

日志

 
 
关于我
Sumner  

美国本特利大学经济学教授

文章分类
网易考拉推荐

如此的美国企业家精神  

2009-06-16 08:30:21|  分类: 默认分类 |  标签: |举报 |字号 订阅

  下载LOFTER 我的照片书  |

    [点击查看Scott Sumner的英文博客 [Scott Sumner中文博客]  

 

《纽约客》上最近刊登了一篇关于美国最贫穷的城区——德州麦卡伦市的医疗保健问题的精彩文章。只有在美国,政府会花钱给某些穷人投保,而在其他方面却一毛不拔:

 

2006年,这个地方每个登记人的医疗保险费用是1.5万美元,几乎相当于全国平均水平的两倍。而这里的人均收入是1.2万美元。也就是说,人均医保费用比人均收入还要多3千美元。

. . .

我对此印象太深刻了。当我顺着南德州一条泥泞的街道一路走过这里的医院时,所闻所见很是不寻常——所有你在哈佛、斯坦福和梅奥医疗中心能够找得到的技术,这里都有。富裕的城镇建起了新校舍,购置了消防车,铺上了平坦的路,更别提那些优秀的教师和警务、公务人员。而贫穷的城镇就什么都不会有。但是这条规律却在医疗保健上失灵了。

 

想象一下,如果麦卡伦市是一个全民医保的独立国家。它的政府要花费多少来确保全体国民都享有医保?如果是独立的,麦卡伦会比美国贫穷,但是在任何绝对意义上,它肯定不是贫穷的。我猜会跟葡萄牙或斯洛文尼亚差不多。而且我还猜测,它用在全体国民医保上的开销会少于我们现在用来投保相对小份额医保覆盖人口的开销。

 

很多左派的人士都宣称我们应该采用欧盟的医保体系。联邦制会是个很好的起点。欧盟和美国的面积差不多大,但是欧盟有27个成员国,每个成员国都有它们自己的医保体系。如果我们照搬欧盟的,第一件要做的事情就是把医保授权给50个州。不再有医保和医补。任何公共医疗保健体系都完全是州级的,就和欧盟一样。当享有盛誉的梅奥医疗中心在医保上的开销是6688美元/人时,我猜休斯顿和达拉斯的优秀公民们都不会热心的为麦卡伦支付1.5万美元/人的费用。如果那些左派人士不能热衷于这个观点,那么我们就不要再听到任何关于采用欧盟医保体系的讨论了。(完成这篇博客之后,我注意到罗宾·汉森有一个更好的观点。)

 

每个人都应该看看《纽约客》的文章,原因之一就是无论你是自由派还是保守派,那上面都有适合你的内容。想想看,是因为牟利而腐蚀了医保系统吗?麦卡伦的例子正说明了这一点。想想看,政府不能控制开支吗?同样也有证据证明这一点。阅读这篇文章的时候我一直在想,所有那些主张“单一承付人”(single-payer)体系的人鼓吹医保开销仅占经常性行政费用的2%。我觉得,如果你稍加努力阻止数千亿美元被从你的项目中盗走,那么缩减行政开销会是件很简单的事。

 

另一个值得关注的事情是,尽管医保事业自1965年就开始了,而问题却是在最近才出现的:

 

1992年,麦卡伦的平均医保费用是4891美元/人,几乎和全国的平均水平一致。但自此以后,年复一年,麦卡伦的医保开销增长的比国内任何地方都快,最终飙升超过了1万美元/人。

 

这是否让你想起了什么?我们的养老金固定收益系统是怎样的情况呢?自1974年我们就已经开始投保养老金了,但是养老基金担保公司(PBGC)的赤字突然激增了。并且根据Reason公布的信息,国家养老金突然更具风险了:

 

大型的公共养老基金存在着利己观念的风险:反正都是他们赢。如果他们靠风险投资碰运气,尽管预定的利润并没有增加,只要还清了债务,他们就是英雄。但是如果这些投资的回报下降了,那就只好用税款来填补

 

或许你想起了联邦储蓄保险公司(FDIC),十几年都运营的相当不错,但是近年来却赤字连连飙升,越来越失调。

 

那么,为什么麦卡伦的医保开销如此之高呢?我首先想到的是风气问题。例如好莱坞的电影《历劫佳人》和《老无所依》让我意识到,是否腐败现象在边境地区很成问题。我还注意到,在明尼苏达州的sqeaky clean,那里的梅奥医疗中心成本很低。但事实并没有支持我的偏见。埃尔帕索的人口数量和麦卡伦极其相似,但是医保费用仅是麦卡伦的一半。南佛罗里达的梅奥分中心可以提供很低成本的医保,尽管附近的迈阿密是美国仅有的、人均医保开销比麦卡伦还高的城市。

 

尽管我那过分简单化的风气解释被证明是错误的,麦卡伦的医保系统仍有可能存在这样一些风气上的问题:

 

在麦卡伦的一个午后,我和心脏外科医师莱斯特·戴克一路沿着McColl Road骑车而下,我们路过一连串的办公广场,那里似乎除了家庭保健中心、影像中心和医疗设备商店就再没有别的什么了。

 

 “我们这儿的药都成了猪槽里的食了,”他抱怨道。

 

戴克是少数几个公开批评麦卡伦这里所发生的事情的人。“当医生不再是医生反而做起了商人的时候,我们没能及时纠正,”他说。

. . .

 

“在埃尔帕索,如果你随便查看一位医生的纳税申报单,85%的收入会是正常的行医所得,”他说到。但是在麦卡伦,行政官员认为这个百分比应该大大的缩小。

 

他知道哪个医生有零售店、橘树林、豪华公寓——或者影像中心、手术中心,或者其他针对患者的医疗部门。他们具备“企业家精神”,他说。他们在想方设法从护理病患中榨取利润方面很能创新、很有干劲。

 

因此,Marcus Welby已经被Gordon Gekko取代了。但是,这不是好事吗?企业家精神不就是美国的全部吗?难道我们不热爱那些努力工作、承担风险的人吗?那些在沿海的洪泛区建造豪华别墅(联邦投保)的人们,无疑显示出了冒险精神。正如储蓄与贷款(S&L)的所有者在上个世纪八十年代把钱(FSLIC投保的)借给投机性的商业发展一样。正如银行家在过去几年里用FDIC投保的资金运作的次级贷款一样。然后,就有这些想用国家养老金做风险投资而蠢蠢欲动的人们。正如这些南德州的医生们,他们是继承了悠久的美国传统的一份子,他们表现出了实实在在的企业家精神。

 

这个国家的问题不是我们太过于自由资本主义。丹麦的市场比我们还要自由。既不是我们的政府太庞大。也不是我们的政府太精简。澳大利亚政府的规模就跟加拿大的差不多。问题是我们发展出一种世界独有的、怪异的公共/私人保健混合体。而且并不能很好的运作。更糟糕的是,由于美国企业家精神的优良传统正快速的搅和着医保体系,而我们又不能及时纠正错误,有迹象表明,这个医保体系的效率越来越低了。

 

如果我们有像欧盟一样的联邦制度,我们将会面对同样的问题,但程度上会小很多。政府越大,剥削越容易。想想最近在洛杉矶建造的4亿美元的高中,然后问问你自己,佛蒙特州或新罕布什尔州的纳税人会不会把钱花在建造这样的学校上。

 

那么,我们应该何去何从?罗宾·汉森说服了我,他使我相信我们花在医保上的大部分钱都是在浪费。所以,新加坡的医疗储蓄账户模式看起来就非常不错。新加坡的医保开支约占GDP5%,并且覆盖全国。反对医疗储蓄账户模式的观点主张——患者没有能力像消费者那样讨价还价:

 

我曾经解释过,第三类医保成本提议将会推动人们使用医疗储蓄账户并且控制高赔付保险政策:“他们希望在危机的时期拥有更多自己的钱,所以这将会使得他们和你或者别的外科医生讨价还价,对吗?”

 

他探询的看看我。我们试图想象那样的情景。一位心脏病专家告知一位年迈的妇女,她需要做心脏搭桥手术,戴克医师会负责她的治疗。他们谈论了她心脏的堵塞情况、手术的操作、以及风险问题。然后现在,他们就应该对价格问题争论一番了,就好像他要在露天集市上卖毛毯一样?“3个脉管我要3万,但如果你需要动4个,那我就要在加护病房里多忙一晚。”——诸如此类的事情吗?戴克摇摇头。“这是谁出的主意?”他问。

 

可以通过4种方式来回答这个问题:

 

1. 直觉

2. 经验证据

3. 经济学理论

4. 反思

 

《纽约客》上的文章就是用了第一种方式——患者缩减开销的想法似乎很愚蠢。但是经济学理论显示,奖励是起作用的,新加坡的经验也证明了这是可行的,并且如果我通过反省意识到许多我的医保开销都不会发生,要不是我仅仅为了从口袋里往外掏钱的话(即使我能轻易的支付)。

 

四种里的三个都还不错,那么我们就好好研究一下第一种方式。请注意,之前所举的例子(心脏搭桥手术)是可能会被包含在灾难保险计划之中的,并且我猜测这类保险公司有能力与医生讨价还价。现在的问题是,绝大多数的知识分子只依靠上面所讲的四个标准中的一个。而且不幸的是,它就是那个最不可靠的——直觉。

 

麦卡伦的腐败风气是怎样形成的呢?我是这样认为的,如果你准备用没必要的身体检查跟一位年迈的妇人多收钱的话,你会面对两个麻烦:

 

1. 她可能会因为缺钱而推迟检查。

2. 你会问心有愧。

 

医保就回避了这两个麻烦。为什么埃尔帕索也有类似的问题?我不清楚,但是如果我们不改变医保体制,不难猜想,最终埃尔帕索将会重蹈麦卡伦的覆辙。

 

当然这种情况早已在银行系统发生了。我们都曾目睹过《风云人物》里那一场令人心碎的情景——吉米·斯图尔特不得不在赔光了储户们的钱后去面对他们。而我们现在的银行家们制造了所有的这些次级贷款却不用面对他们的储户,难道这不是很便利的吗?

 

一些左派人士看出了自上个世纪六十年代以来我们的风气被腐蚀了,他们意识到了问题的严重性。但是我不认为他们完全了解政府投保在腐败中起到了多大的作用。(而且甚至私人医保也是我们税收体制的产物。)或许严格的监管有可能解决问题。但是,我们有什么理由相信,监管一个人口超过3亿的、极其多样化的国家会获得像丹麦那样的成果?尽管市场漏洞百出,好在还可规范行为。或许现在是重新审视新加坡模式的时候了。

 

附:我想很多人都认为目前对于医保的争论是一种对于终端产物的争论。对于我们最后要采用何种医保体制的争论。在我看来却刚好相反。全民医保仅仅是个开始,它是真实较量——成本、基本权利、自由、平等、家长制和所有其他使得加拿大医保体系不同于新加坡医保体系——这一切问题的先决条件。

 

(翻译纠错。读者发现任何翻译错误请发邮件给我们,谢谢:caijingblog#126.com 将#改为@)


英文原文(地址:http://blogsandwikis.bentley.edu/themoneyillusion/?p=1496):

 

That American entrepreneurial spirit 

 

The New Yorker recently published a wonderful article on health care in McAllen Texas, America’s poorest metro area.  Only in America would the government spend a fortune insuring certain poor people, and nothing on others:

In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.

. . .

I was impressed. The place had virtually all the technology that you’d find at Harvard and Stanford and the Mayo Clinic, and, as I walked through that hospital on a dusty road in South Texas, this struck me as a remarkable thing. Rich towns get the new school buildings, fire trucks, and roads, not to mention the better teachers and police officers and civil engineers. Poor towns don’t. But that rule doesn’t hold for health care.

Suppose McAllen was an independent country with universal health care.  How much would it cost the government to insure the entire population?  If independent, McAllen would be poor relative to the US, but it certainly wouldn’t be poor in any absolute sense.  My guess is that it would come in somewhere around Portugal or Slovenia.  And I would also guess that it would spend less insuring the entire population than we now spend insuring the relatively small share of the population covered by Medicare.

Many on the left say we should adopt the European health care system.  A good place to start would be federalism.  The EU is roughly the size of the US, but has 27 members, each with their own health care system.  If we are to copy Europe, the first thing to do is to delegate health care to the 50 states.  No more Medicare and Medicaid.  Any public health care should be fully funded at the state level, just as in Europe.  My guess is that the good citizens of Houston and Dallas are not going to be enthusiastic about spending $15,000 per enrollee in McAllen, when the prestigious Mayo Clinic spends $6688 per enrollee.  If those on the left aren’t enthused about this idea, then let’s not hear any more talk about copying Europe’s health care system.  (After completeing this post I noticed that Robin Hanson had an even better idea.)

One reason why everyone should read The New Yorkerarticle is that it doesn’t matter whether you are a liberal or conservative, it has something for everyone.  Think that the profit motive perverts the health care system?  McAllen certainly supports that theory.  Think that the government can’t control costs?  There’s evidence for that theory as well.  While reading the article I kept thinking of all those single-payer advocates who brag that Medicare only spends about 2% on administrative overhead.  I guess it’s pretty easy to hold down administrative costs if you make little effort to prevent thieves from stealing hundreds of billions of dollars from your program.

Another interesting fact is that the problem is only recent, despite the fact that Medicare has been around since 1965:

In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.

Does this remind you of anything?  How about our defined benefit pension system?  We have insured pensions since 1974, but suddenly the PBGC’s deficit is soaring.  And according to Reason, the state pensions are suddenly taking much bigger risks:

Large public pension funds have a selfish notion of risk: heads they win, tails you lose. If they gamble on risky investments that pay off, they are heroes, although the predetermined benefits don’t increase. But if those investments go south, tax dollars will have to bridge the gap.

Or perhaps it reminds you of FDIC, which seemed to work reasonably well for decades but has grown increasing dysfunctional in recent years.

So why is health care so expensive in McAllen?  My first thought was culture.  Hollywood films like Touch of Evil and No Country for Old Menled me to wonder if corruption was a problem in the border area.  And I also noticed that the low cost Mayo Clinic is in sqeaky clean Minnesota.  But the facts didn’t support my prejudices.  El Paso has very similar demographics, and yet Medicare costs are only half as high as in McAllen.  And the Mayo Clinic was able to offer very low cost health care at a branch in South Florida, despite the fact that nearby Miami is the only city in America where per enrollee Medicare costs are higher than McAllen.

Even though my simplistic cultural explanation turned out to be wrong, there may still be some sort of problem with the culture of health care in McAllen:

One afternoon in McAllen, I rode down McColl Road with Lester Dyke, the cardiac surgeon, and we passed a series of office plazas that seemed to be nothing but home-health agencies, imaging centers, and medical-equipment stores.

“Medicine has become a pig trough here,” he muttered.

Dyke is among the few vocal critics of what’s happened in McAllen. “We took a wrong turn when doctors stopped being doctors and became businessmen,” he said.

. . .

“In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine,” he said. But in McAllen, the administrator thought, that percentage would be a lot less.

He knew of doctors who owned strip malls, orange groves, apartment complexes—or imaging centers, surgery centers, or another part of the hospital they directed patients to. They had “entrepreneurial spirit,” he said. They were innovative and aggressive in finding ways to increase revenues from patient care.

So Marcus Welby has been replaced by Gordon Gekko.  But isn’t this good?  Isn’t entrepreneurial spirit what America is all about?  Don’t we love people who work hard and take risks?  The people who build expensive (federally insured) homes on coastal floodplains certainly show a zest for risk taking.  So do the S&L owners that lent (FSLIC-insured) money in the 1980s for speculative commercial developments.  So did the bankers who made sub-prime loans with FDIC-insured funds in the past few years.  And then there are those state pensions that are showing an increasing penchant for risky investments.  So these South Texas doctors are part of a long American tradition, they are showing real entrepreneurial spirit.

The problem with this country is not that we have too much laissez-faire capitalism.  Denmark has freer markets than we do.  Nor is it that our government is too big.  Nor is it that our government is too small.  Australia and Canada have similar-sized governments.  The problem is that we have developed a weird public/private health care hybrid that is unique in the world.  And it doesn’t work very well.  Even worse, the signs are that it is becoming less efficient at a rapid rate, as that good old American entrepreneurial spirit is finding ways to game the system faster than we can fix the problems.

If we had a federal system like Europe we would face the same sort of problems, but to a much lesser extent.  Bigger governments are simply much easier to rip-off.  Think of the $400,000,000 high school recently built in LA, and ask yourself if the taxpayers in Vermont or New Hampshire would have spent that kind of money on a school.

So where do we go from here?  Robin Hanson has convinced me that most of the money we spend on health care is wasted.  Thus Singapore’s system of health savings accounts looks pretty good.   Singapore spends about 5% of GDP on health care and has universal coverage.  The argument against health savings accounts is that patients aren’t able to negotiate like consumers:

The third class of health-cost proposals, I explained, would push people to use medical savings accounts and hold high-deductible insurance policies: “They’d have more of their own money on the line, and that’d drive them to bargain with you and other surgeons, right?”

He gave me a quizzical look. We tried to imagine the scenario. A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they’re supposed to haggle over the price as if he were selling a rug in a souk? “I’ll do three vessels for thirty thousand, but if you take four I’ll throw in an extra night in the I.C.U.”—that sort of thing? Dyke shook his head. “Who comes up with this stuff?” he asked.

There are 4 ways of thinking about this issue:

1.  Use one’s intuition

2.  Use empirical evidence

3.  Use economic theory

4.  Use introspection

I’ll give point one to The New Yorker, the idea of patients holding down costs seems silly.  But economic theory says that incentives matter, and there is empirical evidence from Singapore that it works, and if I use introspection I notice that many of my health care expenditures never would have happened if I had to pay out of pocket (even though I could easily afford them.)

Three out of four ain’t bad, so let’s take a closer look at point one.  Notice that the example used (bypass surgery) is something that would probably be covered by the catastrophic insurance part of the plan, and I imagine those insurers would be quite capable of bargaining with doctors.  The problem is that the vast majority of intellectuals rely on just one of the four criteria outlined above.  And unfortunately it is the most unreliable—intuition.

How did the culture of corruption develop in McAllen?  Here’s how I think about it.  If you are going to overcharge a little old lady for a useless test, you face two problems:

1.  She might put the test off for financial reasons.

2.  You will have a guilty conscience.

Medicare eliminates those two problems.  Why doesn’t El Paso have similar problems?  I don’t know, but if we don’t change the system I would be surprised if it doesn’t eventually follow in the footsteps of McAllen.

Of course this has already happened in banking.  We’ve all seen the heartwrenching scene in It’s a Wonderful Life where Jimmy Stewart has to face the depositors after losing their money.  Isn’t it convenient that our modern bankers who made all those sub-prime loans don’t have to face their depositors?

The leftists who sense that something has changed for the worse in our culture since the 1960s are on to something.  But I don’t think they fully understand how big a role government insurance has played in the corruption.  (And even private health insurance is a creation of our tax system.)  Perhaps the problem can be fixed with tighter regulation.  But is there any reason to believe that regulating a vast diverse country of over 300,000,000 people will produce the sort of results they get in Denmark?  The market has many flaws but at least it can regulate behavior.  Perhaps it’s time for another look at the Singapore model.

PS.  I think a lot of people view the current fight over health care as a sort of fight over an endpoint.  A fight over the kind of health care system we will “end up” with.  In my view it’s just the opposite.  Universal health care is merely the starting point, the prerequisite for the real fight over cost, privilege, freedom, equality, paternalism, and all the other issues that separate Medicare, the Canadian system, and the Singaporean system.

 [点击查看Scott Sumner的英文博客 [Scott Sumner中文博客]  

  评论这张
 
阅读(3207)| 评论(0)
推荐 转载

历史上的今天

评论

<#--最新日志,群博日志--> <#--推荐日志--> <#--引用记录--> <#--博主推荐--> <#--随机阅读--> <#--首页推荐--> <#--历史上的今天--> <#--被推荐日志--> <#--上一篇,下一篇--> <#-- 热度 --> <#-- 网易新闻广告 --> <#--右边模块结构--> <#--评论模块结构--> <#--引用模块结构--> <#--博主发起的投票-->
 
 
 
 
 
 
 
 
 
 
 
 
 
 

页脚

网易公司版权所有 ©1997-2017