Friday, May 22, 2009

National Healthcare and the Battle of the Sexes

Here is Canada's National Post newspaper on a classic central-planning problem, and associated social conflict, involving the Canadian health-care system:

The growing ranks of female physicians in Canada will slash medical productivity by the equivalent of at least 1,600 doctors within a decade, concludes a provocative new analysis of data indicating that female MDs work fewer hours on average than their male colleagues.

The paper comes just a year after a blue-chip list of medical educators publicly condemned what they called the scapegoating of women for Canada's severe doctor shortage.

The fundamental problem, as I have often noted, in public expectations about health care is that there is no such thing as "universal health care," if by that people assume that they can have any health care they want, anytime they want it. Health care is costly to produce. The resources needed to do so have alternative uses, and so health care must be rationed by some criteria or another.

A "doctor shortage" is unfortunately a term too imprecise to be helpful. According to the article, "The long surgical wait times and lack of family physicians that plague the Canadian health care system are largely blamed on the paucity of doctors.”

But what is the right number of doctors, the number of doctors that ends the "paucity"? The article attempts to answer this question by comparing the number of physicians in Canada to the number in other OECD countries, but Canada is not a copy of other countries. Like every other country, it is a collection of many different individuals. Its individual citizens have different opportunities, different health profiles, different lifestyles, different attitudes toward health. Information about how much each person needs health care is dispersed to each individual; no government agency can possess it all.

We may intelligently speak of an economic shortage, in the sense that, at the prevailing cost of doctors' services to the patient, more people want doctors’ services than there are doctors willing to provide them. (Even this definition is imprecise, but it is close enough.) Canada has this problem in that, according to the article, waiting times are extremely long for both surgery and for services by family physicians.

And somewhat remarkably, the rising presence of female doctors among all Canadian doctors is said to be responsible for this. Women are about a third of Canadian doctors now, but since they're a majority of medical-school students there, they will soon be a much greater share. And since, according to research, women doctors work on average fewer hours than male doctors (because of more claims on their time due to their child-care responsibilities), it only stands to reason that the presence of more female physicians in the workforce will lead to longer wait times. Right?

Alas, this group-based zero-sum thinking is inevitable when genetic groups -- the sexes, races, religions, etc. -- look to the state to referee their disputes. In fact, even if it is true that women on average have more competing claims on their time, so that they devote fewer hours in a week to medical care than male doctors do on average, there are many female doctors for whom this is not true, and many male doctors who also have a high opportunity cost of time. This is the classic example of a problem that a free market solves through its capability to make use of highly decentralized information -- in this case, each physician’s private knowledge about the opportunity cost of his or her own time.

If there are currently more claims on physicians' time than there is time available to be claimed, then the solution to that problem is to raise the compensation for physicians' time. But that is the sort of problem state health-care systems can seldom solve, because they are interested in getting the cost of the entire system down (assuming heroically that they are not interested merely in maximizing politicians’ political success functions by soliciting transfers from special interest groups). What the government should be interested in is encouraging physicians who have sufficient amounts of time, relative to the alternatives, to devote that time to patient care. By allowing the market to set the wage, all such physicians by definition do so. There is no "shortage," although health care is rationed by money instead of by time. But on the other hand, there is no aggregate conflict between male doctors and female doctors. No one blames female doctors are putting in too few hours. Instead, there are only individual doctors, either male or female (it makes no difference), each of whom decides how much time to devote to taking care of patients, and how much time to devote to child care, golfing, or whatever the next best alternate use of his or her time is.

The kind of thinking on display in the article is a result of the belief that good social outcomes only require that the government crunch the right equations. But the Canadian physician shortage is not a function of the aggregate sex composition of Canadian doctors (30 years ago this would have seemed obvious), but the result of the fact that, given what the government has decreed they be paid, too few people are willing to work.

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