html xmlns="" xml:lang="en" lang="en"> From the archives: Open mic

Monday, August 27, 2007

Open mic

OK, folks. Here’s your chance. I completely agree that the state agency, CDCR, failed to provide health care to inmates. Not well, not efficiently, not at all. I have every faith in vesting huge powers in Mr. Sillen and having him fix the problem. But then, I tend to like and trust authority. I don’t think this situation can be remedied any other way.

But you guys do! You loooOOOOooove markets. You want to marry market solutions. You think they’re the best and most efficient solution in very many cases. I cannot figure out how a market solution would work in this case, but maybe you can! Since I don’t have pre-existing expertise about prison health care, I’m willing to hear answers. Given what we’ve got here, which is very many, very sick prisoners who cannot pay for their own care and wards who reflect the public’s opinion that we do not care if they die while in our guardianship, what are potential market solutions? We MUST get prison health care up to Constitutional standards, and you have some power to put make things happen. Please be specific. I am really asking.

If this is too unusual a circumstance, and you can't make a market fit, that's cool. I couldn't either. Do you like the receivership's extraordinary powers in that case, or do you have a better idea? Letting prisoners rot is not an option. We have removed their agency and autonomy; we must either care for them in confinement or we do not sentence them to confinement.


Anonymous Mitch said...

Okay, this might sound like I'm going off on a tangent, but I really think one of the roots of this problem is the limited supply of medical services. And that's one of the places where the licensing vs. certification issue is the sharpest.

In the US we've got millions of uninsured people without access to health care. Now, for the sake of argument, assume we magically come into the billions of dollars it would take to give all those people medical insurance. Does that solve the problem? Absolutely not--we don't have enough doctors and nurses to actually provide medical services to all those people. No matter how much money we spend, we will not have enough people to provide medical services. And the reason for that is that we've artificially limited supply by giving the medical boards a monopoly on the medical education/licensing pipeline. The doctors on those boards have a conflict of interest--they're supposed to be serving the public good but they also have an incentive to restrict competition in their field.

The result is that the education and licensing hurdles are too high, limiting the number of doctors and nurses. Think about all the people that get prevented from being doctors, starting at the undergraduate admissions level, up through the undergrad "weeder" classes, med school admission, med school graduation, and licensing examinations. Each one of those levels excludes people; some levels throw out large numbers of people, many of whom would end up being competent doctors. After all that, is it any wonder we can't give medical care to everyone?

The prison medical care situation is just one symptom of a broader problem. We should allow more people to provide medical care. The best way to do that is to get rid of the licensing system.

The usual argument for licensing is that it protects people from quacks. But certification could do that exactly as well; have a process to give competent people a stamp of approval, but if I can't afford one of those people don't prevent me from going to someone I can afford.

A single-payer medical system doesn't solve this problem; it just changes the rationing mechanism from price to something else.

5:03 AM  
Blogger bobvis said...

We MUST get prison health care up to Constitutional standards,

No fair. Markets are not magic. They cannot be used to ensure that people consume some arbitrary standard, be it constitutional or anything else. The second you *mandate* a certain level of consumption, you are precluding the use of a market.

6:17 AM  
Anonymous Nathan Zook said...

Wholesale conversion of the prison system to private ownership is the only way that a market solution could develop. And note that I mean develop--the transition period would be a serious problem, but I'll even tackle that.

What does private ownership of the prison system give? Someone to sue, of course. The courts have determined that the prisoners have certain rights. The State Bureau of Prison Inspectors is the first line of defense--they impose fines for breaches, but the prisoners can also sue private companies for breach of rights.

The state just has to bid out the job.

The transition is a problem, but in all seriousness, we've got a lot of low-value land east of ElPaso that could be converted to pretty reasonable temporary accommodations. And yes, by "reasonable", I mean "good enough for the army".

Except for health care. Military health care sucks, and not just at the VA.

6:46 AM  
Anonymous mith said...

I'll take a shot at this also.

Put the prisoners in a position where they work for the prison; the wealth they produce through this work would constitute a large portion of the prison's budget, like any other business. Work is voluntary, so prisoners won't work if the jobs are too dangerous or the pay and benefits are not good enough.

"Creating" markets is about finding incentives for both parties to participate in that market. Pay and benefits give the prisoners an incentive to do the work; profiting from that work gives the prison administrators an incentive to keep the prisoners healthy.


6:56 AM  
Anonymous Nathan Zook said...

Sorry to double post, but I have to challenge Mitch.

I have consistently and for a long time observed a substantial problem with nurses attempting to function over their capabilities. No, probably not even the majority, but enough that I basically don't do PAs. If my medical condition is bad enough that I need to go to a professional, then I need a pro, dammit.

The problem is not that it is too hard to become a doctor. The problem is that the pay is to low--once you remove malpractice insurance. The malpractice problem, however, has a certain iron triangle problem.

Doctors can and have been sued for the most trivial and foolish of reasons. To protect their colleagues (and themselves), they have formed a "white wall" wherein, for example, their "ethics" require that if they kick someone out of their practice, that they cannot even inform prospective new partners of the quack that the separation was one-sided. (Compare this to the airline industry and the air safety boards.) The result is that there are a distressingly large number of quacks out there. Thus a lot more medical malpractice than there should be. Thus a lot more lawsuits.

If medicine were to form "medical safety boards" like the airlines, and "ground" quacks like they do pilots, then they would be in a very strong position to fend off frivolous lawsuits. They might even figure a way to put and end to the twenty-year insurance requirement for each birth.

7:00 AM  
Anonymous Anonymous said...

Little time but the general idea would be to create incentives for prisoners' health. For example, the state could promise to pay a company a X dollars if the prisoner stayed healthy for the year, where X is less than what they are spending now. There should be multiple such companies however, competing for prisoners' enrollment in their plans. This would give companies incentives to experiment with different approaches to see what would work best.

Prisoners' health is tricky for multiple reasons. There are safety and security considerations for the medical staff. Probably more important is the fact that prisoners have low incentives to stay healthy - most people are bad at taking care of themselves, and prisoners are far worse (bad at delayed gratification, and the benefits of health are very long term compared with the need to alleviate the boredom of prison).

10:21 AM  
Anonymous Anonymous said...

I'm not sure this is a solution to the prison health care system, and I am pretty sure I'll sound crazy when I say it, but I think the problem you've identified is just a symptom of the larger prison problem.

I don't think there is a good market solution for prisons, ever. The incentives for private prisons don't match up, because the people paying you aren't the people consuming the service (and having prisoners pay for their own jail has its own problems). Allowing prisoners to sue for substandard treatment might help, but it's much cheaper to make malpractice harder to prove than to perform better.

So don't use prisons.

Right now, for something like burglary or drug possession, one's chances of being caught are minuscule. We try to make up for this by creating longer prison sentences when one is caught, but criminals are, almost by definition, bad at time discounting, and increasing jail time does not seem to have a large effect ( ). The prison administrators have almost no incentive to create good conditions, and so they don't. To me, the biggest tragedy is not the poor health care, but the thousands of brutal rapes that occur every day that no one cares enough to stop.

Not only would corporal punishment be more effective, it would be more humane. And I think that even the justice system could handle patching up cuts and bruises immediately afterwards, and that we can monitor them to make sure they do so.

I suspect there are some crimes that will still need jail time (rape, murder), and I don't have a solution for those, although I think a smaller prison population would help.

11:13 AM  
Blogger Amy said...

Here's my market solution. Put some group of people in charge of prison health care. Set up a pool of money from which they will be compensated. Then, every time a prisoner in their care dies, take out a significant chunk of this money. Obviously, some of these deaths won't be preventable, and you'll want to size the pool of available money to take into account a certain baseline acceptable death rate, but I think deaths is the right metric to use simply because that data is very difficult to fudge or hide.

You might also want to add in a carrot aspect to this scheme, where hitting certain benchmarks in overall prison health (mean blood pressure, e.g.) lead to increased money. And you'd want to create an incentive such that chronic but not likely to be fatal conditions don't get undertreated. But basically, you want to pay for health results, not health procedures performed (creating an incentive to over-treat) or a fixed payment (creating an incentive to undertreat).

12:24 PM  
Anonymous Anonymous said...

I'm going to agree with A11:23 here. Singling out just one tiny part of a deeply broken system and trying to fix *just that one part* is almost certainly doomed. Like trying to get the electricity running in Iraq.

It's not a "market" solution, but it is a libertarian one -- decriminalize (hell, legalize) drug use, possession, and sale. Cutting the prison population by ~50% makes every prison-related problem (including health care) twice as easy to solve. More than twice, if you consider network effects.


12:29 PM  
Anonymous Dagon said...

I completely agree with step one: imprison fewer people. Honestly, decriminalizing drugs gets us a long way.

Letting prisoners rot isn't an option, but it IS what voters seem to want, so a democratic solution is unlikely.

The obvious market solution (give the inmates a stipend, which they can spend on food, housing, entertainment, health insurance/care, etc.) seems like a big win, but is politically infeasible for the same reason as above (voters want cheap storage and unpleasant conditions for inmates).

Having a court step in and say "your bureaucracy is broken, please make a new one" is not my favorite answer at first blush, but it's likely the best we can do with the society we have today.

2:59 PM  
Blogger bobvis said...

I don't see these solutions of privatizing prisons as doing anything to implement a market solution for prison health care. The problem Megan cites is that the public is unwilling to pay for prisoner health care. I don't see why they would be any more willing to pay for a private prison to provide prisoner health care. With respect to health care, privatizing the whole prison is no more a market solution than what they have now.

4:04 PM  
Blogger Erik said...

I suspect this is one of those problems I'm always taking about, where the government can do the job at least as well as the next best option, so even though I'm a libertarian I think the government probably should keep the responsibility, especially since it avoids transition costs if we keep things the same.

As many have said, in general we imprison too many people for too long, and this is among the horrible things our government does. If we reorganized our penalty system to rely more heavily on fines, Community service time, and temporary loss of privileges or access to government services, we could significantly reduce the symptom before even looking at the problem.

Megan, I'm curious. Of all the problems with American Health Care (I assume we agree there are many, even if we don't agree on the best way to solve them)do you feel this is one that deserves special attention? I imagine the majority of voters do not mind that criminals get poor health care, and aren't you always a fan of majority rule?

6:36 PM  
Blogger Megan said...

I believe in majority rule within legal boundaries. The Constitution is one of my very favorite legal boundaries.

7:20 PM  
Anonymous Anonymous said...

Hello, Megan.

How do you establish those legal boundaries? If you establish them through a majority, your clarification ("within legal boundaries") is meaningless, isn't it? And if you appeal to a supermajority (which I think just gets you some hysteresis), doesn't your clarification become, "I believe in majority rule, especially when the minority is small"?

What's so special about the Constitution? I see it as either a representation of what we (a majority) believe now, in which case it doesn't add much, or a representation of a past majority's ideals that is used by a current minority to overpower the current majority.

- Jan

8:34 PM  

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