Thirty years ago, Bonnie Svarstad and Chester Bond of the School of Pharmacy at the University of Wisconsin-Madison discovered an interesting pattern in the use of sedatives at nursing homes in the south of the state.
Patients entering church-affiliated nonprofit homes were prescribed drugs roughly as often as those entering profit-making �proprietary� institutions. But patients in proprietary homes received, on average, more than four times the dose of patients at nonprofits.
Writing about his colleagues� research in his 1988 book �The Nonprofit Economy,� the economist Burton Weisbrod provided a straightforward explanation: �differences in the pursuit of profit.� Sedatives are cheap, Mr. Weisbrod noted. �Less expensive than, say, giving special attention to more active patients who need to be kept busy.�
This behavior was hardly surprising. Hospitals run for profit are also less likely than nonprofit and government-run institutions to offer services like home health care and psychiatric emergency care, which are not as profitable as open-heart surgery.
A shareholder might even applaud the creativity with which profit-seeking institutions go about seeking profit. But the consequences of this pursuit might not be so great for other stakeholders in the system � patients, for instance. One study found that patients� mortality rates spiked when nonprofit hospitals switched to become profit-making, and their staff levels declined.
These profit-maximizing tactics point to a troubling conflict of interest that goes beyond the private delivery of health care. They raise a broader, more important question: How much should we rely on the private sector to satisfy broad social needs?
From health to pensions to education, the United States relies on private enterprise more than pretty much every other advanced, industrial nation to provide essential social services. The government pays Medicare Advantage plans to deliver health care to aging Americans. It provides a tax break to encourage employers to cover workers under 65.
Businesses devote almost 6 percent of the nation�s economic output to pay for health insurance for their employees. This amounts to nine times similar private spending on health benefits across the Organization for Economic Cooperation and Development, on average. Private plans cover more than a third of pension benefits. The average for 30 countries in the O.E.C.D. is just over one-fifth.
We let the private sector handle tasks other countries would never dream of moving outside the government�s purview. Consider bail bondsmen and their rugged sidekicks, the bounty hunters.
American TV audiences may reminisce fondly about Lee Majors in �The Fall Guy� chasing bad guys in a souped-up GMC truck � a cheap way to get felons to court. People in most other nations see them as an undue commercial intrusion into the criminal justice system that discriminates against the poor.
Our reliance on private enterprise to provide the most essential services stems, in part, from a more narrow understanding of our collective responsibility to provide social goods. Private American health care has stood out for decades among industrial nations, where public universal coverage has long been considered a right of citizenship. But our faith in private solutions also draws on an ingrained belief that big government serves too many disparate objectives and must cater to too many conflicting interests to deliver services fairly and effectively.
Our trust appears undeserved, however. Our track record suggests that handing over responsibility for social goals to private enterprise is providing us with social goods of lower quality, distributed more inequitably and at a higher cost than if government delivered or paid for them directly.
The government�s most expensive housing support program � it will cost about $140 billion this year � is a tax break for individuals to buy homes on the private market.
According to the Tax Policy Center, this break will benefit only 20 percent of mostly well-to-do taxpayers, and most economists agree that it does nothing to further its purported goal of increasing homeownership. Tax breaks for private pensions also mostly benefit the wealthy. And 401(k) plans are riskier and costlier to administer than Social Security.
From the high administrative costs incurred by health insurers to screen out sick patients to the array of expensive treatments prescribed by doctors who earn more money for every treatment they provide, our private health care industry provides perhaps the clearest illustration of how the profit motive can send incentives astray.
By many objective measures, the mostly private American system delivers worse value for money than every other in the developed world. We spend nearly 18 percent of the nation�s economic output on health care and still manage to leave tens of millions of Americans without adequate access to care.
Britain gets universal coverage for 10 percent of gross domestic product. Germany and France for 12 percent. What�s more, our free market for health services produces no better health than the public health care systems in other advanced nations. On some measures � infant mortality, for instance � it does much worse.
In a way, private delivery of health care misleads Americans about the financial burdens they must bear to lead an adequate existence. If they were to consider the additional private spending on health care as a form of tax � an indispensable cost to live a healthy life � the nation�s tax bill would rise to about 31 percent from 25 percent of the nation�s G.D.P. � much closer to the 34 percent average across the O.E.C.D.
A quarter of a century ago, a belief swept across America that we could reduce the ballooning costs of the government�s health care entitlements just by handing over their management to the private sector. Private companies would have a strong incentive to identify and wipe out wasteful treatment. They could encourage healthy lifestyles among beneficiaries, lowering use of costly care. Competition for government contracts would keep the overall price down.
We now know this didn�t work as advertised. Competition wasn�t as robust as hoped. Health maintenance organizations didn�t keep costs in check, and they spent heavily on administration and screening to enroll only the healthiest, most profitable beneficiaries.
One study of Medicare spending found that the program saved no money by relying on H.M.O.�s. Another found that moving Medicaid recipients into H.M.O.�s increased the average cost per beneficiary by 12 percent with no improvement in the quality of care for the poor. Two years ago, President Obama�s health care law cut almost $150 billion from Medicare simply by reducing payments to private plans that provide similar care to plain vanilla Medicare at a higher cost.
Today, again, entitlements are at the center of the national debate. Our elected officials are consumed by slashing a budget deficit that is expected to balloon over coming decades. With both Democrats and Republicans unwilling to raise taxes on the middle class, the discussion is quickly boiling down to how deeply entitlements must be cut.
We may want to broaden the debate. The relevant question is how best we can serve our social needs at the lowest possible cost. One answer is that we have a lot of room to do better. Improving the delivery of social services like health care and pensions may be possible without increasing the burden on American families, simply by removing the profit motive from the equation.
