UncertaintyandtheWelfare Economicsof MedicalCare KennethJ.Arrow TheAmericanEconomic Review,Vol.53,No.5.(Dec.,1963),pp.941-973. StableURL: http://links.jstor.org/sici?sici=0002-8282%28196312%2953%3A5%3C941%3AUATWEO%3E2.0.CO%3B2-C TheAmericanEconomicReviewiscurrentlypublishedbyAmericanEconomicAssociation. YouruseoftheJSTORarchiveindicatesyouracceptanceofJSTOR'sTermsandConditionsofUse,availableat http://www.jstor.org/about/terms.html.JSTOR'sTermsandConditionsofUseprovides,inpart,thatunlessyouhaveobtained priorpermission,youmaynotdownloadanentireissueofajournalormultiplecopiesofarticles,andyoumayusecontentin theJSTORarchiveonlyforyourpersonal,non-commercialuse. Pleasecontactthepublisherregardinganyfurtheruseofthiswork.Publishercontactinformationmaybeobtainedat http://www.jstor.org/journals/aea.html. EachcopyofanypartofaJSTORtransmissionmustcontainthesamecopyrightnoticethatappearsonthescreenorprinted pageofsuchtransmission. TheJSTORArchiveisatrusteddigitalrepositoryprovidingforlong-termpreservationandaccesstoleadingacademic journalsandscholarlyliteraturefromaroundtheworld.TheArchiveissupportedbylibraries,scholarlysocieties,publishers, andfoundations.ItisaninitiativeofJSTOR,anot-for-profitorganizationwithamissiontohelpthescholarlycommunitytake advantageofadvancesintechnology.FormoreinformationregardingJSTOR,[email protected]. http://www.jstor.org SunDec216:25:242007 THE AMERICAN ECONOM C REVIE DECEMBER 1963 VOLUME LIII NUMBER 5 UNCERTAINTY AND THE WELFARE ECONOMICS OF MEDICAL CARE I. Introdz~ction:S cope and ~Wethod This paper is an exploratory and tentative study of the specific differentia of medical care as the object of normative economics. It is contended here, on the basis of comparison of obvious characteris- tics of the medical-care industry with the norms of welfare economics, that the special economic problems of medical care can be explained as adaptations to the existence of uncertainty in the incidence of dis- ease and in the efficacy of treatment. It should be noted that the subject is the medical-care industry, not health. The causal factors in health are many, and the provision of medical care is only one. Particularly at low levels of income, other commodities such as nutrition, shelter, clothing, and sanitation may be much more significant. It is the complex of services that center about the physician, private and group practice, hospitals, and public health, which I propose to discuss. The focus of discussion will be on the way the operation of the medical-care industry and the efficacy with which it satisfies the needs of society differ from a norm, if at all. The "norm" that the econo- mist usually uses for the purposes of such comparisons is the operation of a competitive model, that is, the flows of services that would be *The author is professor of economics at Stanford University. I-Ie wishes to express his thanks for useful comments to F. Eatoi, R. Dorfman, V. Fuchs, Dr. S. Gilson, R. Kessel, S. Mushkin, and C. R. Rorem. This paper was prepared under the sponsorship of the Ford Foundation as part of a series of papers on the economics of health, education, and welfare. 942 THE AMERICAN ECONOMIC REVIEW offered and purchased and the prices that would be paid for them if each individual in the marliet offered or purchased services at the going prices as if his decisions had no influence over them, and the going prices were szch that the amounts of services which were available equalled the total amounts which other individuals were willing to purchase, with no imposed restrictions on supply or demand. The interest in the competitive model stems partly from its pre- sumed descriptive power and partly from its implications for econoinic efficiency. In pzrticular, we can state the following well-known prop- osition (First Optimality Theorem). If a conipztitive equilibrium exists at all, and if all commodities relevant to costs or utilities are in fact priced in the market, then the equilibrium is necessarily optimal in the folloxx-;ving precise sense (due to V. Pareto): There is no other a1lo:atian of resources to services which will inake all participants in the ~ilarkebt etter off. Both the co:~ditionso f this optimality theorem and the definition of optimality call for comment. A definition is just a definition. but when the dcfiniendunz is a word already in common use with highly favor- able connotations, it is clear that me are really trying to be pcrsvasive; we are implicitly reconlmending the achievement of optimal states.' It is reasoilable enough to assert that a change in allocation which makes all participants better off is one that certajnly should be nade; this is a value judgment, not a descriptive proposition, but it is a very weak one. From thjs it follows that it is not desirable to put up with a non- optimal allocation. But it does not folloxv that if vx are at an ailoca- tion which is optimal in the Pareto sense, we should not change to any other. We cacnot indeed make a change that does not hurt someone; but we can still desire to change to another allocation if the change makes enough participants better off and by so much that xT;e feel that the injury to others is not enough to offset the benefits. Such inter- personal comparisons are, of course, value judgments. The change, however, by the previous argument ought to be an optimal state; of course there are many possible states, each of which is optinlal in the sense here used. However, a value judgment on the desirability of each possible new distribution of benefits and costs corresponding to each possible re- allocation of resources is not. in general, necessary. Judgments about the distribution can be made separately, in one sense, from those about allocation if certain conditions are fulfilled. Eefore stating the relevant proposition, it is necessary to remark that the competitive equilibrium achieved depends in good measure on the initial distribution of pur- chasing power, which consists of ownership of assets and skills that 'This point has been stressed by I. M. D. Little [19, pp. 71-74]. For the concept of a "persuasive definition," see C. L. Stevenson [27, pp. 210-171. ARROW: UNCERTAINTY AND MEDICAL CARE 943 command a price on the market. A transfer of assets among individ- uals will, in general, change the final supplies of goods and services and the prices paid for them. Thus, a transfer of purchasing power from the well to the ill will increase the demand for medical services. This will manifest itself in the short run in an increase in the price of medical services and in the long run in an increase in the amount sup- plied. With this in mind, the following statement can be made (Second Optimality Theorem) :If there are no increasing returns in production, and if certain other minor conditions are satisfied, then every optimal state is a competitive equilibrium corresponding to some initial dis- tribution of purchasing power. Operationally, the significance of this proposition is that if the conditions of the two optimality theorens are satisfied, and if the allocation mechanism in the real world satisfies the conditions for a competitive model, then social policy can confi~eit self to steps taken to alter the distribution of purchasing power. For any given distribution of purchasing power, the market will, under the assumptions made, achieve a competitive equilibrium which is neces- sarily optimal; and any optimal state is a competitive equilibrium cor- responding to some distribution of purchasing power, so that any desired optimal state can be achieved. The redistribution of purchasing power among individuals most simply takes the form of money: taxes and subsidies. The implications of such a transfer for individual satisfactions are, in general, not known in advance. But we can assume that society can ex post judge the distribution of satisfactions and, if deemed unsatisfactory, take steps to correct it by subsequent transfers. Thus, by successive ap- proximations, a most preferred social state can be achieved, with re- source allocation being handled by the market and public policy con- fined to the redistribution of money income.' If, on the conti-ary, the actual market differs significantly from the competitive model, or if the assumptions of the two optimality the- orems are not fulfilled, the separation of allocative and distributional procedures becomes, in most cases, impo~sible.~ The first step then in the analysis of the medical-care market is the a The srnaration between allocation and distribution even under the above assumptions has :,.los;:d os.er prob1e:n; in the e:;ecutior, of 3r1y desired redistribution policy; in przctice, it is virtually impossible to find a set of taxes and subsidies that will not have an ad- verse effect on the achievement of an optimal state. But this discussion would take us even further afield than we have already gone. 'The basic theorems of welfare economics alluded to so briefly above have been the subject of voluminous literature, but no thoroughly satisfactory statement covering both the theorems themselves and the significance of exceptions to them exists. The pcsitive assertions of welfare economics and their relation to the theory of competitive equilibrium are admirably covered in ICoopmans [IS]. The best summary of the various ways in which the theorems can fail to hold is probably Bator's [61. 9.44 THE AMERICAN ECONOMIC REVIEW comparison between the actual market and the competitive model. The methodology of this comparison has been a recurrent subject of con- troversy in economics for over a century. Recently, M. Friedman [IS] has vigorously argued that the competitive or ar,y other model should be tested solely by its ability to predict. In the context of competition, he comes close to arguing that prices and quantities are the only rele- vant data. This point of view is valuable in stressing that a certain amount of lack of realism in the acsumptions of a model is no argu- ment against its value. But the price-quantity irnplicai-ions of the com- petitive model for pricing are not easy to derive without major--and, in many cases, impossible-econometric efiorts. In this paper, the institutional organization and the observable mores of the medical profession are included among the data to be used in awessing the coinpetitiveness of tlie medical-care market. I shall also examine the presence or absence of the preconditions for the equiva- lence of competitive equilibria and optimal states. The major competi- tive preconditions, in the sense used here, are three: the existence of competitive equilibrium, the ma~ketnhilityof all goods and services relevant to cocts and utilities, and noflincreasing ret;rn.ns. The first two, as we have seen, insure that competitive equilibrium is necessarily op- timal; the third insures that every optimal state is the competitive equilibrium corresponding to some distribution of income.Yhe first and third conditions are interrelated; indeed, nonincreasing returns plus some additional conditions not restrictive in a modern economy imply the existence of a competitive equilibrium, i.e., imply that there will be some set of prices which will clear all markets." The concept of marketability is somewhat broader than the tradi- tional divergence between private and social costs and benefits. The latter concept refers to cases in which the organization of the market does nct reqaire an individual to pay for coqts that he imposes on others as the result of his actions or does not permit him to receive compensation for benefits he confers. In the medical field, the obvious example is the spread of communicable diseases. An individual who fails to be immunized not only risks his own health, a disutility which presumably he has weighed against the utility of avoiding the proce- dure, but also that of others. In an ideal price system, there would be a price which he would have to pay to anyone whose health is endan- gered, a price sufficiently high so tllat the others would feel compen- sated; or, alternatively, there would be a price which would be paid to him by others to induce him to undergo the immunization procedure. *There are further minor conditions, for which see Koopmans [IS, pp. 50-551. For a more precise statement of the existence conditions, see Koopmans 118, pp. 56-60] or Debreu [12, Ch. 51. ARROW : UNCERTAINTY AND MEDICAL CARE 945 Either system would lead to ail optimal state, though the distributional implications would be different. It is, of course, not hard to see that such price systems could not, in fact, be practical; to approximate an optima! state it would be necessary to have collective intervention in the form of subsidy or tax or compulsion. By the absence of marketability for an action which is identifiable, technologically possible, and capable of influencing some individual's welfare, for better or for worse, is meant here the failure of the exist- ing market to provide a means whereby the services can be both of- fered and demanded upon payment of a price. Nonniarketability may be due to intrinsic techiiological characteristics of the product which prevent a suitable price from being enforced, as in the case of com- municable diseases, or it may be due to social or historical controls, such as those prohibiting an individual from selling himself into slav- ery. This distinction is, in fact, difficult to make precise, though it is obviously of i~nportancef or policy; for the present purposes, it will be sufficient to identify non~narketabilityw ith the observed absence of markets. The instance of nonmarketability with which x7e shall be most con- cerned is that of risk-bearing. The relevance of risk-bearing to medical care seems obvious; illness is to a considerable extent an unpredictable phenomenon. The ability to shift the risks of illness to others is worth a price which many are willing to pay. Because of pooling and of supe- rior ?villingness and ability, others are willing to bear the risks. Never- theless, as we shall see in greater detail, a great many risks are not covered, and indeed the markets for the services of risk-coverage are poorly developed or nonexistent. Why this should be so is explained in more detail in Section 1V.C below; briefly, it is impossible to draw up insurance policies which will sufficiently distinguish among risks, par- ticularly since observation of the results will be incapable of distin- guishing between avoidable and unavoidable risks, so that incentives to avoid losses are diluted. The optimality theorems discussed above are usually presented in the literature as referring only to conditions of certainty, but there is no difficulty in extending them to the case of risks, provided the addi- tional services of risk-bearing are included with other c~niniodities.~ However, the variety of possible risks in the w~rldis really stagger- ing. The relevant commodities include, in effect, bets on all possible occurrences in the world which impinge upon utilities. In fact, many of these "commodities," i.e., desired protection against many risks, are 6Tl~eth eory, in vxiant forms, seems to have teen first worked out by hllais 123, Arrow [5],and BauCier [I]. For further generalization, see Debreu [ll] and [I.?, Ch. 71. 946 THE AMERICAN ECONOMIC REVIEJV simply not available. Thus, a wide class of commodities is nonmarket- able, and a basic competitive precondition is not sati~fied.~ There is a still more subtle consequence of the introduction of risk- bearing considerations. When there is uncertainty, information or knowledge becomes a commodity. Like other commodities, it has a cost of production and a cost of transmission, and so it is naturally not spread out over the entire population but concentrated among those who can profit most from it. (These costs may be measured in time or disutility as well as money.) But the demand for information is diffi- cult to discuss in the rational terms usually employed. The value of information is frequently not known in any meaningful sense to the buyer; if, indeed, he knew enough to measure the value of informa- tion, he would know the information itself. But information, in the form of skilled care, is precisely what is being bought from most physi- cians, and, indeed, from most professionals. The elusive character of information as a commodity suggests that it departs considerably from the usual marketability assumptions about commodities.' That risk and i~ncertaintya re, in fact, significant elements in medi- cal care hardly needs argument. I will hold that virtually all the special features of this industry, in fact, stem from the prevalence of uncer- tainty. The nonexistence of markets for the bearing of some risks in the first instance reduces welfare for those who wish to transfer those risks to others for a certain price, as well as for those who would find it profit- able to take on the risk at such prices. But it also reduces the desire to render or consume services which have risky consequences; in techni- cal language, these commodities are complementary to risk-bearing. Conversely, the production and consumption of commodities and serv- ices with little risk attached act as substitutes for risk-bearing and are encouraged by market failure there with respect to risk-bearing. Thus the observed commodity pattern will be affected by the nonexistence of other markets. 'It should also be remarked that in the presence of uncertainty, indivisibiiities that are sufficiently small to create little difficulty for the evistence and viability of competitive equilibrium may nevertheless give rise to a considerable range of increasing returns be- cause of the operation of the law of large numbers. Since most objects of insurance (lives, fire hazards, etc.) hare some element of indivisibility, insurance companies have to be above a certain si7e. Gut it is not clezr that this effect is sufficiently great to create serious obstacles to the existence and viability of competitive equilibrium in practice. 'One form of production of information is research. Not only does the product have unconventionsl aspects as a commodity, but it is also subject to increasing returns in use, since new ideas, once developed, can be used over and over without being consumed, and to difiiculties of market control, since the cost of reproduction is usually much less than that of production. Hence, it is not surprising that a free enterprise economy will tend to underinvest in research; see Nelson [211 and Arrow [4]. ARROW: UNCERTAIYTY AND MEDICAI, CARE 947 The failure of one or more of the competitive preconditions has as its most immediate and obvious consequence a reduction in welfare below that obtainable from existing resources and technology, in the sense of a failure to reach an optimal state in the sense of Pareto. But more can be said. I propose here the view that, when the market fails to achieve an optimal state, society will, to some extent at least, recog- nize the gap, and nonmarket social institutions will arise attempting to bridge it.Tertainly this process is not necessarily conscious; nor is it uniformly successful in approaching rnore closely to optinlality when the entire range of consequences is considered. It has al~~abyese n a favorite activity of econonlists to point out that actions which on their face achieve a desirable goal may have less obvious consequences, particularly over time, which more than offset the original gains. But it is contended here that the special structural characteristics of the medical-care market are largely attempts to overcome the lack of optimality due to the nonmarketability of the bearing of suitable risks and the imperfect marketability of icforination. These compensatory institutional changes, with some reinforcement from usual profit mo- tives, largely explain the observed noncompetitive behavior of the medical-care market, behavior ~vhich,i n itself, interferes with opti- mality. The social adjustment towards optimality thus puts obstacles in its own path. The doctrine that society will seek to achieve optimality by non- market means if it cannot achieve them in the market is not novel. Certainly, the government, at least in its economic activities, is usually implicitly or explicitly held to function as the agency which substitutes for the market's failure.'' I am arguing here that in some circum- stances other social institutions will step into the optimality gap, and that the medical-care industry, with its variety of special institutions, some ancient, some modern, exemplifies this tendency. It may be useful to remark here that a good part of the preference for redistribution expressed in government taxation and expenditure policies and private charity can be reinterpreted as desire for insur- ance. It is noteworthy that virtually nowhere is there a system of sub- sidies that has as its aim simply an equalization of income. The sub- sidies or other governmental help go to those who are disadvantaged in life by events the incidence of which is popularly regarded as unpre- 'An important current situation in which normal market relations have had to be greatly modified in the presence of great risks is the production and procurement of modern weapons; see Peck and Scherer [23, pp. 581-821 (I am indebted for this refer- ence to V. Fuchs) and [I, pp. 71-75], 10 For an explicit statement of this view, see Baumol [81. But I bciieve this position is implicit in most discussions of the functions of government. 948 THE AMERICAN ECONOMIC REVIEW dictable: the blind, dependent children, the medically indigent. Thus, optimality, in a context which includes risk-bearing, includes much that appears to be motivated by distributional value judgments when looked at in a narrower context.'' This methodological background gives rise to the following plan for this paper. Section I1 is a catalogue of stylized generalizations about the medical-care market which differentiate it from the usual cornmod- ity markets. In Section I11 the behavior of the market is compared with that of the competitive model which disregards the fact of uncer- tainty. In Section IV, the medical-care market is compared, both as to behavior and as to preconditions, with the ideal competitive market that takes account of uncertainty; an attempt will be made to demon- strate that the characteristics outlined in Section I1 can be explained either as the result of deviations from the competitive preconditions or as attempts to compensate by other institutions for these failures. The discussion is not designed to be definitive, but provocative. In particu- lar, I have been chary about drawing policy inferences; to a consider- able extent, they depend on further research, for which the present paper is intended to provide a framework. 11. A Survey of the Special Characteristics of the Medical-Care Market12 This section will list selectively some characteristics of medical care which distinguish it from the usual commodity of economics textbooks. The list is not exhaustive, and it is not claimed that the characteristics listed are individually unique to this market. But, taken together, they do establish a special place for medical care in economic analysis. A. The Nature of Demand The most obvious distinguishing characteristics of an individual's demand for medical services is that it is not steady in origin as, for example, for food or clothing, but irregular and unpredictable. Medi- cal services, apart from preventive services, afford satisfaction only in the event of illness, a departure from the normal state of affairs. It is hard, indeed, to think of another commodity of significance in the average budget of which this is true. A portion of legal services, de- voted to defense in criminal trials or to lawsuits, might fall in this cate- gory but the incidence is surely very much lower (and, of course, there 11 Since writing the above, I find that Buchanan and Tullock [lo, Ch. 131 have argued that all redistribution can be interpreted as "income insurance." "For an illuminating survey to which I am much indebted, see S. Mushkin [201. ARROW: UNCERTAINTY AND MEDICAL CARE 949 are, in fact, strong institutional similarities between the legal and medical-care markets.)13 In addition, the demand for medical services is associated, with a considerable probability, with an assault on personal integrity. There is some risk of death and a more considerable risk of impairment of full functioning. In particular, there is a major potential for loss or reduc- tion of earning ability. The risks are not by themselves unique; food is also a necessity, but avoidance of deprivation of food can be guaranteed with sufficient income, where the same cannot be said of avoidance of illness. Illness is, thus, not only risky but a costly risk in itself, apart from the cost of medical care. B. Expected Behavior of the Physician It is clear from everyday observation that the behavior expected of sellers of medical care is different from that of business men in gen- eral. These e:ipectations are relevant because medical care belongs to the category of commodities for which the product and the activity of production are identical. In all such cases, the customer cannot test the product before consuming it, and there is an element of trust in the relation.'" But the ethically understood restrictions on the activities of a physician are much more severe than on those of, say, a barber. His behavior is supposed to be governed by a concern for the customer's welfare which would not be expected of a salesman. In Talcott Par- sons's terms, there is a "collectivity-orientation,') which distinguishes medicine and other professions from business, where self-interest on the part of participants is the accepted norm.15 A few illustrations will indicate the degree of difference between the behavior expected of physicians and that expected of the typical busi- nessman.'' (1) Advertising and overt price competition are virtually eliminated among physicians. (2) Advice given by physicians as to further treatment by himself or others is supposed to be completely "In governmental demand, military power is an example of a service used only irregularly and unpredictably. Here too, special institutional and professional relations have emerged, though the precise social structure is different for reasons that are not hard t3 analyze. "Even with material commodities, testing is never so adequate that all elements of implicit trust can be eliminated. Of course, over the long run, experience with the quality of product of a given seller provides a check on the possibility of trust. See 122, p. 4631. The whole of 122, Ch. 101 is a most illuminating analysis of the social role of medical practice; though Parsons' interest lies in different areas from mine, I must acknowledge here my indebtedness to his work. "I am indebted to Herbert Klarman of Johns Hopkins University for some of the points discussed in this and the following paragraph.