This essay, written in 2013, is 1470 words long
Government efforts to improve health care are plagued by a proliferation of meaningless micro-targets, perverse incentives for drug companies, and glaring inconsistencies and inefficiencies. As in other areas of government intervention, government is, usually, well meaning and hard working. But it suffers from its inherently uniform, top-down approach. It can also be short term in its thinking, reactive rather than proactive, discouraging of innovation while favouring tried, tested but failed approaches.
Government has to make its resource allocation decisions on the basis of data that are necessarily incomplete. How can it know in detail the effect that spending on, say, cancer diagnostic machinery will have on the overall health of the nation, as compared with subsidising the cost of nicotine chewing gum? So, by default, health expenditure is influenced by groups of medical specialists with little incentive or capacity to see improvements in the overall health of the nation as an objective. Funding decisions are also heavily influenced by the public profile of a disease or its victims, rather than on what would best meet the needs of society. It’s also a question of diet, exercise, transport, and culture. Recent research shows, for instance, the beneficial effects on health of green spaces in our cities (see here (pdf) for instance). The way government is structured, with its discrete funding bodies, makes it unlikely that such benefits will influence funding decisions.
We cannot expect a government nor any single organization to identify the huge numbers of variables, with all their time lags and interactions, that influence the nation’s health. We can, though, devise a system that rewards people who explore and implement the most cost-effective health solutions, even when circumstances and knowledge are changing continuously.
We propose that government targets broad, explicit health goals for the whole country. This could be a combination of variables, each of which has to fall into a specified range before the target is deemed reached. The variables would be likely to include: longevity, Quality Adjusted Life Years , infant mortality and other objective and, ideally, easily acquired data.
Government would then issue and back a large number of tradable non-interest bearing bonds, redeemable for (say) $1m each once the target health goals have all been achieved and sustained. The bonds would initially be floated on the open market. If the health targets are ambitious, then the bonds would fetch a correspondingly low price, perhaps just a few dollars. Importantly (see Why the bonds must be tradeable, under Features in the left-hand menu), the bonds would be tradable: investors would bid for the bonds because, if they then do something, however small, to improve the nation’s health, the value of their bonds would rise. The price of Health Bonds would be quoted openly; it would depend entirely on the market’s view of how likely it is that the government’s health goals will be achieved quickly. That it turn would depend on the market’s view of how effective bondholders’ investors will be, and on other variables beyond the control of bondholders. Investors could sell their bonds at any time, realizing any capital gain they have made, and allowing new investors to take the next steps toward reaching society’s health target. Bondholders would have incentives to co-operate with each other in researching and implementing the most cost-effective ways of improving the nation’s health. This includes setting up payment systems that rewards people in ways that maximize their contribution to the targeted health outcomes.
We cannot say much either about the projects that the new regime would stimulate. Our scientific knowledge is rapidly expanding. New opportunities, new technology and new threats are constantly emerging. A Health Bond regime rewards those people who can best maximize health outcomes in the face of new challenges. Perhaps as important, it motivates people to terminate failed approaches rather than, as can happen under the current system, continue to fund projects that do little to improve society’s overall health.
Neither can we know in advance the structure or employees of the organizations that would flourish in a Health Bond regime. They might consist mainly of brokers: people or institutions who buy large numbers of the bonds and allocate funding as they see fit. What we can say is that whichever organizations come into being their activities will be solely dedicated to achieving society’s health goals as efficiently as possible. If at any point they become inefficient, would-be investors will bid more for the bonds than their market value, and the inefficient holders will be better off selling them. This is in contrast to today’s system in which, as with any other health organization, be it a hospital, church, government agency, trade union or educational establishment, the over-arching objective is self-perpetuation. Under a Health Bond regime the membership, structure and activities of any organization involved in improving the nation’s health would be subordinated to society’s goal - that of reaching society’s explicit target, as set out by the government.
Free-riders, hoping to benefit from holding the bonds but doing nothing would, if they held too many bonds, see the value of their bonds falling, and sell to investors who would find it profitable to work to achieve the health target.
Efficiency would be the main benefit that a Health Bond regime would offer. At every stage of every project, bondholders would seek to maximise the improvement in society’s health per dollar expenditure. Impartiality as to how resources are allocated would contribute to better efficiency. We’d very probably see more funding for preventive health and proportionately more for the less glamorous aspects of health care - like the diseases that celebrities don’t want to talk about. (See also here or here.) In stark contrast to the medical sector itself, with its constantly emerging new threats, new technologies and rapidly expanding scientific knowledge, society’s health goals, as articulated and targeted by government, would be stable over time. So another contributor to efficiency would be the stability of targeted outcomes over one or several decades, which would promote long-term thinking and mean that rational allocation of resources would not be undermined by high-profile events, as here, for example.
As well as efficiency a Health Bond regime would have other benefits: one is clarity. There is often a confusion between ends and means that bedevils policy. Hospitals become adept at achieving micro-targets, such as minimizing waiting times, which might do little to improve health outcomes, which often entail administrative time and effort, and which can easily be gamed so that even if the targets are ostensibly achieved, that is done by undertaking activities that conflict with society’s other goals. (See here, for instance.) Transparency of health policy goals is another benefit. People readily understand broad health goals: far more so than we do the legislation, structures and funding arrangements of bodies that are supposed to achieve them. More public understanding means more public participation in their formulation. That can be an end in itself as well as promoting more buy-in.
A Health Bond regime would stimulate diverse approaches to our problems. The best way of, say, improving overall health in one part of the country might be to lay on taxis for drunken youths: in another, to subsidise the continued operation of a factory with employees who might otherwise turn to drink or drugs. Bondholders would have incentives to look at all potential influences on good health. They could beef up the way in which drug companies conduct their research and publicity. They could lobby for lower speed limits on certain roads. They could work on improving the access to contraception or literacy classes for women in immigrant communities. They would have incentives to look at all aspects of health, and to invest returns in projects that yield the best health outcome per dollar spent. Health Bonds would generate more adaptive approaches than under the current system: bondholders will have incentives to react swiftly to changing circumstances and our rapidly expanding scientific knowledge, and, crucially, to terminate failed approaches.
The effect of a Health Bond regime would be that government rewards successful initiatives for improving health regardless of how these initiatives work or who implements them. Government would still articulate society's broad desired health outcomes, and would still raise the revenue for their achievement. These are tasks that democratic governments do very well. Where government does less well is in actually achieving our social goals: that is a resource allocation question. Economic theory and all the evidence show that markets are the best way of allocating scarce resources. A Health Bonds regime would see government continuing to set our goals and raise the necessary revenue, while allowing market forces to do what they do best: achieving these goals at minimum cost to society.
You might also be interested in my April 2016 blog post entitled Health is not an accountancy issue or my August 2015 post entitled Smoking and obesity; anxiety and sirens. Other recent blog posts on why we should target broad health outcomes rather than surrogate indicators can be found here, here and here.