Wynand P.M.M. van de Ven

Wynand P.M.M. van de Ven

Dr Wynand van de Ven (1950) wrote his thesis “Studies in Health Insurance and Econometrics” at Leiden University. Since 1986 he is professor of Health Insurance at the Erasmus University Rotterdam. His teaching and research focus on managed competition in health care, competitive health insurance market, risk selection, moral hazard, risk equalisation, managed care and priority choices in health care. He has experience as a governor and adviser of insurance companies, political parties, government, research institute, hospitals and other health care organizations. He serves (served) as member of many advisory committees and the editorial Board of scientific journals. As a consultant, e.g. for the World Bank and the World Health Organization, he has studied the health care systems in Chile, Ireland, Israel, New Zealand, Poland, Russia, South Africa and Sweden. He is one of the founding fathers of the European Risk Adjustment Network. Previous positions are Programme Director of the Master Health Economics, Policy and Law at Erasmus University and Chair of the iHEA Jury-Committee for the annual Arrow Award for best paper in health economics.

Selected publications:

Ven, WPMM van de and BMS van Praag,
‘The demand for deductibles in private health insurance; a probit model with sample selection’,
Journal of Econometrics 17 (1981), 229-252.

Ven, WPMM van de,
“Ziektekostenverzekering en financiële prikkels tot doelmatigheid; Deel I: Op weg naar een volksverzekering; Deel II: Contouren van een Algemene Wet Ziektekosten”,
Economisch Statistische Berichten 68 (1983), 72-78, 110-117

Ven, WPMM van de, RCJA van Vliet, FT Schut, EM van Barneveld,
Access to coverage for high-risks in a competitive individual health insurance market: via premium rate restrictions or risk-adjusted premium subsidies?
Journal of Health Economics 19 (2000) 311-339.

Ven, WPMM van de, R.P Ellis,
Risk adjustment in competitive health plan markets,
Handbook of Health Economics, Volume 1, Edited by A.J. Culyer and J.P. Newhouse, Elsevier Science B.V. 2000, 755-845.

Van de Ven, WPMM., RCJA van Vliet, LM Lamers,
‘Health-adjusted premium subsidies in the Netherlands’,
Health Affairs, vol 23, No. 3, May/June 2004, 45-55.

1986-present: Professor of Health Insurance, Erasmus University Rotterdam
1983 – 1986: Associate professor, Erasmus University Rotterdam
1981: Visiting research associate, RAND Corporation, Santa Monica, U.S.
1976 – 1982: Assistant professor, University of Leiden
1973 – 1976: Research-assistent, University of Leiden

Erasmus University Rotterdam
Department of Health Policy and Management
Health Insurance

P.O. Box 1738
3000 DR Rotterdam
Tel: +31 10 408 8556 / 8525

vandeven@bmg.eur.nl

http://oldwww.bmg.eur.nl/personal/vandeven/

Wynand P.M.M. van de Ven

Wynand P.M.M. van de Ven

Wynand van de Ven

Wynand P.M.M. van de Ven

Wynand P.M.M. van de Ven

Wynand P.M.M. van de Ven

Alain Enthoven, Marriner S. Eccles Professor of Public and Private Management, Emeritus, Stanford University, Center for Health Policy delivers remarks at San Francisco health care reform discussion

***

Alain Enthoven

Unrealistic Expectations Born of Defective Institutions
Alain C. Enthoven and Sara J. Singer

We, Americans, planted the seeds of the managed care backlash in the design of the health care and insurance institutions we created.

The traditional model of health insurance based on fee-for-service, complete free choice of provider, and indemnity insurance (FFS), which was for many years the main form of insurance in this country, left providers largely unaccountable for the cost of care. When caring for insured people, providers could resolve every doubt in favor of doing more with no direct negative financial consequences for patients or themselves. When combined with rapidly expanding technology, these incentives led national health expenditures to increase rapidly through the 1980s, from 8.9 percent of gross domestic product (GDP) in 1980 to 13.6 percent in 1993 (Iglehart 1999).

Equally important, FFS failed to hold health care institutions and professionals accountable for the quality of the services they provided or for the health of the populations they served. Under FFS, there were very wide variations in medical practices. Researchers found five- and ten-fold variations in the per capita incidence of surgeries in different communities with no evidence of such differences in medical need or health produced (Wennberg and Cooper 1998; see also Iglehart 1984). Variations seemed to be determined more by “practice style” than by scientific evidence. This “cost-unconscious” milieu also produced large amounts of inappropriate treatments. Research found that 32 percent of carotid endarterectomies and 14 percent of coronary artery bypass surgeries were performed for [End Page 931] inappropriate reasons, with many more for equivocal reasons (Winslow et al., Coronary Artery Bypass, 1988; Winslow et al., Carotid Endarterectomy, 1988). A study in the New England Journal of Medicine found 23 percent of hospital admissions to be inappropriate, another 17 percent avoidable through use of ambulatory surgery (Siu et al. 1986).

The growth rate in national health expenditures inevitably would have to be brought into approximate equality with that of the GDP. High and rapidly increasing health expenditures create serious social problems. They strain public finances; government now pays 47 percent of the health care bill (Iglehart 1999). They reduce the growth in real wages for working people. They price health insurance out of reach for families of moderate means; 43 million people in this country are now uninsured.

In these circumstances, any serious expenditure limitation strategy would need to attempt to create standards of appropriateness, to examine and curtail inappropriate use of services, and therefore to limit the autonomy and authority of health professionals. Thus any serious expenditure limitation policy would have caused a backlash among physicians.

Although many physicians in many medical groups have embraced managed care, recognized the need for quality and cost management, and accepted responsibility for it, many other physicians, especially those in solo practice, regret the demise of FFS and their transition to managed care. Outside of Kaiser Permanente and other multispecialty groups, most physicians do not contract with HMOs by choice, but rather have been driven to them for financial survival. Many of these physicians–particularly specialists–fear a loss of income due to managed care. 1 Doctors’ unwillingness to accept responsibility to organize and manage care has created a vacuum into which health plans have moved. As a result, health plans are performing functions that upset physicians and patients.

Physicians could have headed off the loss of autonomy and authority and could now correct the situation by following the examples of doctors in prepaid group practice. These physicians have created a culture of conservative practice, peer utilization management and review, and a management structure that enables them to respond to demands for cost containment. As a result, they are responding to national economic pressures by reexamining and redesigning care processes, innovating in ways that reduce people’s need for care, and even by taking salary [End Page 932] reductions. In exchange, no one outside their medical groups micromanages their practices.

Resolving this cause of the backlash will require that physicians accept the inevitability of cost containment and take responsibility for managing quality and cost. Physicians need to become actively involved in continuous quality improvement, including evaluation of practice variations, identification and promulgation of best practices, and monitoring of compliance in partnership with professional managers who can assist them (Berwick, Godfrey, and Roessner 1991; Ellwood 1988; Roper et al. 1988). To the extent that physicians are not willing to accept these responsibilities, someone else will have to manage costs, which will be less acceptable to physicians and patients. This may take a long time because it will require a major cultural change. Physicians generally were not selected or trained for management or teamwork.

Cost unconsciousness characterized consumers as well as providers during the FFS era. The inevitable correction also contributed to the backlash. Because employers typically paid all or most of the premium, consumers did not see themselves as personally involved in premium costs. Consumers do not commonly perceive that premiums ultimately come out of their wages (Fuchs 1993). (Employers may pay for premium increases out of profits in the short run, but not in the long run when they have had time to take them out of what would have been wage increases.) From that position of complete freedom and economic nonresponsibility, almost any change would have had to be a change for the worse, and bound to cause dissatisfaction.

Over the past decade, large numbers of consumers were converted–often involuntarily–from the freedom of FFS coverage to the limitations of HMOs, often without much explanation of the relationship between the limitations and cost containment. 2 Neither the employers nor the managed care organizations wanted to emphasize the limitations on choice of doctor, so people approached managed care with the expectations they had acquired under FFS. Suddenly, people found themselves under limitations they had not experienced before. In many cases, people were forced to change doctors, not permitted to go to the doctor they wanted, or were denied proposed medical procedures. Because they experienced no direct financial benefit, these differences between FFS and managed care coverage were perceived as pure “takeaway.” [End Page 933]

All this was made worse by the fact that large numbers of people were offered no choice of health insurance plan. A survey by Atul Gawande et al. (1998) of Harvard found that 42 percent of Americans with employer-based health insurance had no choice of plan. Even of those with choices, 20 percent complained they did not have enough variety of choice, and 31 percent of the total sample said their employer forced them to change health plans in the past five years. This and other surveys found that people without choices were much more likely to be dissatisfied with their health insurance and to have complaints about it. Indeed, dissatisfaction levels among those without choice are typically twice as high as among those with choices (Davis and Shoen 1997).

A great deal of consumer dissatisfaction could have been avoided if employers had created arrangements similar to the Federal Employees Health Benefits Program, the California Public Employees Retirement System, the University of California, Stanford University, Harvard University, and others that are models of responsible multiple choice of plan. Consumers must perceive a direct personal interest in economical medical care. Otherwise, they have no reason to accept any limitations. To accomplish this, consumers must know what their health care costs are and that higher premiums come out of their pay. Difficult as it has been for employers, employees should be required to pay the full premium difference (adjusted for the health status of enrollees if possible) for a more expensive health plan. This would encourage consumers to seek value when purchasing coverage and create pressure on health plans to offer high-quality care for the lowest possible price. A limit on tax-free employer contributions might help employers overcome employee resistance to offering a contribution set at the tax-free limit and to require employees to pay the difference in premiums. Less than 10 percent of Americans have choices of plan and full economic responsibility for premium differences (Hunt et al. 1997).

If well-informed, cost-conscious consumers were given a choice of plan, ranging from FFS to preferred provider insurance to point-of-service to various types of HMOs, people could consciously make decisions on what they thought was in their own best interest. 3 Then people would see that they could save substantial sums of money by accepting the limitations [End Page 934] of managed care, and gradually most people would do so. The people who really wanted FFS and were willing to pay for it could have that, too.

While cost consciousness in consumers’ choice of health plan will foster competition and reduce price, alone it is likely to be insufficient to appease the backlash. Enrollees in HMOs pay little at the point of service–usually a $5 or $10 copayment for a physician’s visit and zero for hospitalization–and therefore have little or no incentive to accept less costly care. The RAND Health Insurance Experiment suggests that patients might respond differently if they were required to pay part of the cost of each of the services they receive (Newhouse et al. 1981).

These two elements, doctors angered by loss of authority, autonomy, and income, and consumers who have seen their freedoms replaced by restrictions with no apparent direct personal benefit, have made managed care a tinderbox in which incidents, real or imagined, can produce national conflagrations. For example, “early” (i.e., within twenty-four hours) hospital discharge for uncomplicated vaginal deliveries was tested in numerous studies with inconclusive medical results. Neither proponents nor opponents had good data on which to base their cases. But when HMOs and other insurers attempted to implement this as a standard for coverage–in the context of a crisis atmosphere regarding health care costs and intense pressure from government and employers to restrain premiums–in 1995 and 1996, 25 states and the federal government adopted early discharge laws generally requiring coverage of forty-eight-hour stays for uncomplicated vaginal deliveries. As Declercq and Simmes (1997) observe in a review of the history, “The legislation was politically symbolic, capturing the frustration of consumers and physicians with HMOs.” A recent study reported that such legislation in Maryland, the first state to adopt it, added about $5.5 million to the annual cost for maternity stays (Udom and Betley 1998).

Of course, HMOs are not helpless victims of the managed care backlash. Rather, at times they seem to be their own worst enemies. Some health plans have resisted market-improving legislation, in part because they may benefit from market imperfections that allow them to attract healthy populations while avoiding the sick. The industry generally has not supported responsible multiple-choice arrangements. Some health plans have needlessly antagonized physicians in their cost control efforts rather than try to find ways to win their cooperation in an effort to improve quality while reducing costs. Many have done a poor job of recognizing and responding to reasonable and legitimate consumer and [End Page 935] patient concerns. Although this behavior is not true of all health plans and not always true of any of them, such resistance, lack of responsiveness, and antagonistic behavior reflect negatively on the industry. The industry needs to be more proactive in the early identification and resolution of problems.

Managed care as we see it today is an innovation and a work in progress. In response to demands by government and employers for cost containment, there is a great deal of trial and error as plans try to figure out new ways to control costs while not injuring or antagonizing patients. Mistakes are inevitable.

Mistakes have long been commonplace in medicine. For example, the Harvard Medical Practice Study, done for the State of New York by a multidisciplinary team of some of the most distinguished scholars in their fields, examined hospital care in New York in 1984 and estimated that in that year there were 98,609 cases of unintended injuries caused by medical management. Of these, 27,179 cases were due to negligence. Fourteen percent of the injured patients, or 13,805, died at least in part as a result of their adverse event, and about 2,500 cases of permanent total disability resulted from medical injury (Harvard Medical Practice Study 1990). Managed care was minimal in New York that year, so managed care had virtually nothing to do with these events one way or the other.

Ironically, we have not seen a medical injury backlash. Sustained public support for medical quality improvement has been hard to create. We have not seen, for example, congressional legislation to require hospitals to implement computerized drug-ordering systems that reduce errors. And yet, studies of drug dosing errors show many patients are injured by such mistakes in hospitals (Leape et al. 1991; Bates et al. 1995). In California, the legislature has not acted to prevent the forty hospitals doing coronary artery bypass surgery in volumes below the minimum recommended for patient safety by the specialty societies.

The mistakes of managed care (and some nonmistakes, such as twenty-four-hour hospital stays for uncomplicated deliveries) are being judged very differently than the mistakes of the rest of medicine. People are not fighting the mistakes; they are fighting the idea of limits on their medical care, even though limits are inevitable, and some limits–like disapproval of inappropriate surgery–may be good for their health.

There are real problems about this industry that require regulation to make the market work, such as the need for standards and disclosure of information. Among the most important is the lack of responsible consumer [End Page 936] choice from among a variety of plans. Solving these problems is an appropriate role for legislation if the industry does not do so itself. Hundreds of thousands of consumers in California alone called their elected officials about problems with their health plans (MHCTF 1998). It is thus not surprising that politicians want to be seen as responding with new legislation. Piecemeal legislation, however, won’t solve the fundamental problems of the backlash.

The managed care backlash is the consequence of the inevitable introduction of financial restraint into health care. Without such restraint and even perhaps despite it, national health expenditure growth in excess of the present 13.5 percent of GDP will create costs in the form of increased numbers of uninsured, reductions in public health programs, higher taxes, and crowding out other important public expenditures on education, infrastructure, criminal justice, and so on. Doctors could have avoided the distasteful loss of authority if they had accepted responsibility to control costs themselves and surrendered their autonomy to their peers in an organized effort to manage care. Patients would have experienced much less dissatisfaction if they had gotten to managed care through informed responsible choices that they saw as in their own best interest. While managed care organizations are inevitably imperfect human institutions that sometimes make mistakes; the backlash does not stem primarily from the failings of managed care. It stems from resource constraints and the failing of many doctors to step up to the responsibility to manage the cost of care themselves.

Stanford University

Alain C. Enthoven is the Marriner S. Eccles Professor of Public and Private Management in the Graduate School of Business at Stanford University. He holds degrees in economics from Stanford, Oxford, and MIT.

Sara J. Singer is executive director of the Center for Health Policy at Stanford University and a senior research scholar at Stanford’s Graduate School of Business. She holds an A.B. in English and European cultural studies from Princeton University and a M.B.A. from Stanford University. As staff director and chairman, respectively, she and Alain Enthoven led the California Managed Health Care Improvement Task Force, which addressed health care issues raised by managed care to aid in policy decisions.
Notes

1. Recent indications suggest that doctors nationwide have not suffered an actual loss of income, but rather fear a loss of income and perceive that they must work harder to earn the same amount (see Kilborn 1998).

2. In an HMO, patients may receive covered services only from providers contracting with their HMO.

3. Preferred provider insurance resembles FFS augmented by a list of providers who have agreed to accept the health plan’s fees as payment in full and by incentives to choose those providers. A point-of-service plan is an HMO augmented by a preferred provider insurance plan for those patients who want access to a wider network of providers and are willing to pay more out-of-pocket when accessing them.
References

Bates, D. W., D. J. Cullen, N. Laird, L. A. Peterson, S. D. Small, D. Servi, G. Laffel, B. J. Sweitzer, B. F. Shea, and R. Hallisey. 1995. Incidence of Adverse Drug Events and Potential Adverse Drug Events: Implications for Prevention. Journal of the American Medical Association 274(1):29-34.

Berwick, D., B. Godfrey, and J. Roessner. 1991. Curing Health Care: New Strategies for Quality Improvement. San Francisco: Jossey-Bass.

Davis, K., and C. Schoen. 1997. Managed Care, Choice, and Patient Satisfaction. New York: Commonwealth Fund, August.

Declercq, E., and D. Simmes. 1997. The Politics of “Drive-Through Deliveries”: Putting Early Postpartum Discharge on the Legislative Agenda. Milbank Quarterly 75(2):175-202.

Ellwood, P. 1988. Shattuck Lecture–Outcomes Management: A Technology of Patient Experience. New England Journal of Medicine 318(23):1549-1556.

Fuchs, V. 1993. It’s Not Employers Who Bear the Costs. Los Angeles Times, 21 September, B7.

Gawande, A., R. Blendon, M. Brodie, J. M. Benson, L. Levitt, and L. Hugick. 1998. Does Dissatisfaction with Health Plans Stem from Having No Choices? Health Affairs 17(5):184-194.

Harvard Medical Practice Study. 1990. Patients, Doctors, and Lawyers: Medical Injury, Malpractice Litigation, and Patient Compensation in New York. Cambridge, MA: Harvard.

Hunt, K., S. Singer, J. Gabel, D. Liston, and A. C. Enthoven. 1997. Paying More Twice: When Employers Subsidize Higher-Cost Health Plans. Health Affairs 16(6):150-156.

Iglehart, J., ed. 1984. Special issue: Variations in Medical Practice. Health Affairs 3(2).

——. 1999. The American Health Care System: Expenditures. New England Journal of Medicine 340(1):70-76.

Kessler, D., and M. McClellan. 1996. Do Doctors Practice Defensive Medicine? Working Paper Series, no. 5466. Cambridge, MA: National Bureau of Economic Research.

Kilborn, Peter. 1998. Doctors’ Pay Regains Ground Despite Effects of HMOs. New York Times, 22 April, A1.

Leape, L. L., T. A. Brennan, N. Laird, A. G. Lawthers, A. R. Localio, B. A. Barnes, L. Hebert, J. P. Newhouse, P. C. Weiler, and H. Hiatt. 1991. The Nature of Adverse Events in Hospitalized Patients: Results of the Harvard Medical Practice Study 2. New England Journal of Medicine 324(6):377-384.

Managed Health Care Improvement Task Force of California (MHCTF). 1998. Public Perceptions and Experiences with Managed Care. Background paper, 5 January.

Newhouse, J., W. Manning, C. Morris, L. Orr, N. Duan, E. B. Keeler, A. Leibowitz, K. H. Marquis, M. S. Marquis, C. E. Phelps, and R. H. Brooks. 1981. Some Interim Results from a Controlled Trial of Cost Sharing in Health Insurance. New England Journal of Medicine 305(25):1501-1507.

Roper, W. L., W. Winkenweerder, G. M. Hackbarth, and H. Krakauer. 1988. Effectiveness in Health Care: An Initiative to Evaluate and Improve Medical Practice. New England Journal of Medicine 319(18):1197-1202.

Siu, A. L., F. A. Connenberg, W. G. Manning, G. A. Goldberg, E. S. Bloomfield, J. P. Newhouse, and R. H. Brook. 1986. Inappropriate Use of Hospitals in a Randomized Trial of Health Insurance Plans. New England Journal of Medicine 315(20):1259-1266.

Udom, N., and C. Betley. 1998. Effects of Maternity-Stay Legislation on “Drive Through Deliveries.” Health Affairs 17(5):208-215.

Wennberg, J. E., and M. M. Cooper, eds. 1998. The Dartmouth Atlas of Health Care in the United States. Chicago: American Hospital Publishing.

Winslow, C. M., J. B. Kosecoff, M. R. Chassin, D. E. Kanouse, and R. H. Brook. 1988. The Appropriateness of Performing Coronary Artery Bypass Surgery. Journal of the American Medical Association 260(4):505-509.

Winslow, C. M., D. H. Solomon, M. R. Chassin, J. B. Kosecoff, J. Merrick, and R. H. Brook. 1988. The Appropriateness of Carotid Endarterectomy. New England Journal of Medicine 318(12):721-727.

http://muse.jhu.edu

The Three Big Ideas of Alain Enthoven, Paul Ellwood and Jack Wennberg
By Jim Jaffe – Health Care Editor on January 2, 2010

As negotiators work quietly to come up with a health reform compromise that is either the beginning of the end or the end of the beginning–depending on one’s political perspective, it is worth taking a moment to consider the role of the three men who constituted the beginning of the beginning when they began agitating more than a quarter century ago: Alain Enthoven, Paul Ellwood and Jack Wennberg. The three big ideas that Enthoven, Ellwood and Wennberg started refining and promoting prior to the start of the Reagan presidency are the pillars of the bill that will soon become law. They also provide some insight into the pace of political change in American society.

Enthoven, a professor at the Stanford business school who worked for Defense Secretary Robert McNamara during the Johnson years, like many economists, believes in the power of markets. Enthoven quickly concluded that the medical market was dysfunctional because it wasn’t really a market at all, with transparency and negotiation between buyers and sellers typical of other transactions. He then came up with a series of reforms designed to create a market environment that would, he was convinced, give us greater control over escalating costs, which were then quite modest by today’s standard.

Ellwood, a Minnesota physician who provoked decades of experiments in the Twin Cities area, was dedicated to creating a system where a provider-insurer entity was paid a single flat-fee to care for a patient over time, perhaps via a health maintenance organization, so that providers would have an incentive to consider the cost of care and challenge the traditional relationship where providing more care yielded greater revenue. His thinking had an impact on the government’s continuing effort in promoting capitated plans that began with the Nixon Administration’s commitment to HMOs in the early 1970s.

Wennberg, a physician at Dartmouth, endlessly collected and analyzed data providing that there was a tremendous disparity between the amount of care provided for a given diagnosis from one geographic area that had no impact on outcomes. Wennberg came to believe there were many regions where care could be cut significantly – at one point suggesting that Medicare expenditures could be slashed by 30% — without necessarily impacting care.

All three of these basic insights – each of which has a complexity and density that I’ve failed to do justice to here – are now part of the new conventional wisdom that is contained in the upcoming new law.

Each learned the difficulty of translating theory into practice. Enthoven concluded once again that while transparent markets may yield the best overall results, satisfied players in opaque transactions will resist change.

Ellwood, a doctor, learned the hard way that patients were extremely reluctant to transfer decisions for their care from physicians, who often could earn more by doing more, to HMOs or managed care entities that had greater incentives to perform efficiently.

And Wennberg, who was subjected to recurring challenges even while added research confirmed his basic insight, never inspired as someone whose prescriptive abilities complemented his diagnostic skills.

Each of the three casts a big shadow over the new world now being created.

http://www.centeredpolitics.com/

Toward a 21st-Century Health Care System: Recommendations for Health Care Reform

Kenneth Arrow, PhD; Alan Auerbach, PhD; John Bertko, BS; Shannon Brownlee, MS; Lawrence P. Casalino, MD, PhD; Jim Cooper, JD; Francis J. Crosson, MD; Alain Enthoven, PhD; Elizabeth Falcone; Robert C. Feldman, MD; Victor R. Fuchs, PhD; Alan M. Garber, MD, PhD; Marthe R. Gold, MD, MPH; Dana Goldman, PhD; Gillian K. Hadfield, JD; Mark A. Hall, JD; Ralph I. Horwitz, MD; Michael Hooven, MS; Peter D. Jacobson, JD, MPH; Timothy Stoltzfus Jost, JD; Lawrence J. Kotlikoff, PhD; Jonathan Levin, PhD; Sharon Levine, MD; Richard Levy, PhD; Karen Linscott, MA; Harold S. Luft, PhD; Robert Mashal, MD; Daniel McFadden, PhD; David Mechanic, PhD; David Meltzer, MD, PhD; Joseph P. Newhouse, PhD; Roger G. Noll, PhD; Jan B. Pietzsch, PhD; Philip Pizzo, MD; Robert D. Reischauer, PhD; Sara Rosenbaum, JD; William Sage, MD, JD; Leonard D. Schaeffer; Edward Sheen, MD, MBA; B. Michael Silber, PhD; Jonathan Skinner, PhD; Stephen M. Shortell, PhD, MPH; Samuel O. Thier, MD; Sean Tunis, MD; Lucien Wulsin, Jr., JD; Paul Yock, MD; Gabi Bin Nun, MA; Stirling Bryan, PhD; Osnat Luxenburg, MD; and Wynand P.M.M. van de Ven, PhD

Abstract

The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care to substantially changing the organization and delivery of care. The FRESH-Thinking Project (www.fresh-thinking.org) held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others who represent diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform:

• Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment.

• Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions.

• Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions.

• Develop a health information technology infrastructure with national standards of interoperability to promote data exchange.

• Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make de-identified information from this database on clinical interventions, patient outcomes, and costs available to researchers.

• Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans.

• Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees’ coverage.

• Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges.

***
The FRESH-Thinking project (http://www.fresh-thinking.org) convenes a multidisciplinary group of scholars who collaborate to comprehensively study the specific, detailed challenges to health care reform. This group represents diverse sectors of the health care system and beyond—physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others. Through the FRESH-Thinking project, the authors met in a series of 8 workshops to delineate “essential foundations” necessary for fundamental reforms in the U.S. health care system.

Despite diverse perspectives and policy positions, the group agreed that the United States must create a health care system that provides all Americans access to an affordable, standard benefits package. We must simultaneously build the capabilities, infrastructure, and incentives to ensure that all Americans receive high-quality care. Through an iterative process of debate and comment, we found common ground on 8 fundamental policy recommendations to achieve these aims.

In formulating the recommendations, we achieved consensus on the following underlying observations and principles: First, the main problems of the U.S. health care system—coverage, cost, and quality—are well understood and well documented. Second, improving access alone is insufficient. Most discussions about reforming the system primarily focus on how to finance expanded coverage. Sustainable reform, however, must substantially change both the financing of care and the systems for organizing and delivering care. Finally, doing nothing is not an option. Maintaining the status quo in health care represents a significant threat to government finances, the economy, Americans’ standard of living, and our nation’s future.

It is impossible to solve the problem of access to health care services without fixing the financing system. But without fixing the delivery system, it is impossible to solve the cost and quality problems in a sustainable manner. Escalating costs will undermine access, and poor quality will add costs and undermine the overall value of health care coverage. Patchwork and haphazard incremental changes have not and will not create a sustainable system. Reform requires a systematic, goal-directed process; new programs and policies must offer a coordinated and coherent approach, and they must reinforce each other. For instance, a health information technology infrastructure and better outcomes measures are necessary to pay physicians and other providers on the basis of results, but merely providing the infrastructure without reasons for clinicians to use it will simply add expense.

Reform of the health system will not occur overnight. We must find a place to start. Mindful of the urgency, we have formulated these 8 recommendations as an essential foundation to achieve needed fundamental reforms regardless of the particular policy options chosen. Some of the recommendations pertain to reform of the delivery system and others to reform of the financing system.

Reform of the Delivery System

1. Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment.

Current payment mechanisms reward the provision of narrowly defined services and increased product volume, independent of appropriateness or health outcomes. Instead, payments should be linked to improving patient outcomes, reducing racial and other disparities in outcomes, increasing efficiency, and moderating the growth in the cost of care. Linking payment to outcomes will require continued investment in the systematic development of outcomes measures.

Current efforts are laudable, but they should be augmented with the development and rigorous evaluation of additional pilot and demonstration projects that use different payment mechanisms, such as bundled or global payments and capitation, as well as new ways of organizing and delivering care. These projects must use clear performance criteria so that the system rewards the approaches known to improve patient outcomes or save resources and terminates those that compromise patient outcomes or increase the cost of care. Because of their important role in the health care system, Medicare and Medicaid can lead the efforts in payment reform.

2. Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions.

Data are lacking on the effectiveness of medical interventions and processes of care. An independent agency not subject to interest-group pressures should sponsor both analyses of existing data and new research on the effectiveness, comparative effectiveness, and cost-effectiveness of health care diagnostics, therapeutics, procedures, and processes of care. All public and private payers (including self-insured organizations) benefit from such assessments and should contribute resources to funding the agency. The data, analytic methods, and evaluative criteria used should be transparent and the results of its research widely disseminated to the public, physicians, government agencies, insurers, and other health care providers to inform health decisions.

3. Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions.

Both federal and state laws and regulations provide inconsistent requirements that frequently inhibit reform of the health care system, especially the coordination of care among various providers and more effective use of physicians, nurses, and other providers. Reform should include, but not be limited to, state laws and regulations governing the corporate practice of medicine doctrine and scope of practice limitations. The states should retain authority for enforcement of provider licensure, credentialing, and consumer protections. Federal and state laws should be revised to allow gain-sharing in situations with bundled or aggregated payments that improve patient outcomes, reduce disparities, or enhance efficiency.

4. Develop a health information technology infrastructure with national standards of interoperability to promote data exchange.

Effective deployment of health information technology is essential for collecting data on outcomes to guide quality improvement. A successful health information “superhighway” requires the rapid development and implementation of national standards for interoperability and exchange of electronic data to facilitate the collection and sharing of data on health care quality, outcomes, and cost throughout the health care system.

5. Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make de-identified information from this database on clinical interventions, patient outcomes, and costs available to researchers.

Most health plans and health care providers do not effectively use existing data to improve the efficiency and quality of care. The expansion of health information technology recommended above will provide additional sources of valuable data. To effectively use these data in improving the health care system, national standards should be implemented for combining the data to ensure consistency and comparability. Researchers using transparent and established methods should have as much access as possible, but patient confidentiality and an appropriate level of proprietary interests should be protected.

Reform of the Financing System

6. Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans.

Everyone is aware of the tens of millions and growing numbers of uninsured Americans. More than 70% of these Americans lack insurance because they cannot afford it. Revenue sources, including but not limited to savings from capping the tax exclusion of employer-based health insurance, taxing tobacco, and redirecting existing health resources, should be mobilized to ensure coverage for all Americans.

7. Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees’ coverage.

Because of risk selection and underwriting, the small group and individual insurance markets perform poorly. Exchanges in which insurance companies offer a standard benefits package with guaranteed issue, portability, and renewability and no exclusions for preexisting conditions can expand the offerings to small groups and persons at lower rates. Along with mandatory coverage for standard benefits, the exchanges must implement risk-adjusted payments to minimize adverse selection. These mandates on insurance companies must be matched by mechanisms to ensure complete participation of those eligible to prevent the accumulation of only high-risk persons within the exchange. Potential mechanisms include substantial subsidies, possibly combined with enforceable mandates. Employers should be allowed to participate in these exchanges for their employee coverage.

8. Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges.

For insurance exchanges to operate efficiently with competition on cost and value, they must have standard benefits packages. Design of these standard benefits packages will entail attention to many technical details and tradeoffs. An independent board with broad input would be best able to formulate options for standards benefits packages that Congress and the current administration could accept or reject. These packages could also define the base coverage that employer-based plans must meet to be eligible for tax exclusions. Individual participants should have the option to purchase packages with more coverage.

The challenge of creating consensus is significant but surmountable. The FRESH-Thinking project demonstrates that, despite diverse backgrounds and interests, people can agree on fundamental elements that will provide a solid foundation for a health care system. The essence of these elements is the reform and modernization of how we both finance and deliver health care to ensure real value—better quality care and improved health of Americans at sustainable growth in costs.

http://www.annals.org/content/150/7/493.full

Alain Enthoven

ალან ენთჰოვენი – Alain Enthoven

Alain C. Enthoven at blackboard during briefing on sac budget, at Rand Corporation Research Institute

Alain C. Enthoven at blackboard during briefing on sac budget at Rand Corporation Research Institute

Alain Enthoven

Alain Enthoven

Alain Enthoven

Alain Enthoven

Alain Enthoven

Alain Enthoven

ალან ენთჰოვენი – Alain Enthoven

Alain C. Enthoven (born September 10, 1930) is an American economist. Professor Alain Enthoven has published widely in the fields of the economics, organization, management and public policy of health care in the U.S.A. and U.K. In his research, he studies the causes of unsustainable growth in national health expenditures and the costs of health insurance, and possible strategies for moderating this growth while improving quality of care. His recent work is focused on the failings of employment-based health insurance and on proposals for market-based universal health insurance in the U.S.A.

Professor Enthoven holds degrees in Economics from Stanford, Oxford, and Massachusetts Institute of Technology (MIT) . He began his teaching career in 1955 while an Instructor in Economics at Massachusetts Institute of Technology (MIT). In 1956, he moved to the RAND Corporation (Research ANd Development Corporation) in Santa Monica and participated in continuing studies on U.S. and NATO defense strategies. In 1960, he moved to the Department of Defense, where he held several positions leading to appointment, by President Johnson, to the position of Assistant Secretary of Defense for Systems Analysis in 1965. His work there is described in the book How Much is Enough? coauthored with K. Wayne Smith and published by the RAND Corporation. In 1963, he received the President’s Award for Distinguished Federal Civilian Service from John F.Kennedy. In 1969, he became vice president for Economic Planning for Litton Industries, and in 1971 he became president of Litton Medical Products. In 1972, he was elected to the Institute of Medicine of the National Academy of Sciences and served on its governing Council. He joined the Stanford Faculty in 1973, and began teaching Business Policy and, later, Microeconomics. In 1977, while serving as a consultant to the administration of President Carter, he designed and proposed Consumer Choice Health Plan, a plan for universal health insurance based on managed competition in the private sector. Since 1980, his teaching has been focused on health care.

Professor Enthoven is a fellow of the American Academy of Arts and Sciences. He is Chairman of Stanford’s Committee on Faculty/Staff Human Resources. He has been a consultant to the Kaiser Permanente Medical Care Program since 1973. He has served as Chariman of the Health Benefits Advisory Council for CalPERS, the California State employees’ medical and hospital care plans. He has been a director of the Jackson Hole Group, PCS, Caresoft Inc. and eBenX, Inc. He is a member of the research advisory board of the Committee for Economic Development. He was the 1994 winner of the Baxter Prize for Health Services Research and the 1995 winner of the Board of Directors Award of the Healthcare Financial Management Association. In 2008, he was awarded the honorary degree of Doctor of Public Policy by the RAND Graduate School.

In 1997, Governor Wilson appointed him Chairman of the California Managed Health Care Improvement Task Force. Commissioned by the State legislature, the Task Force addressed healthcare issues raised by managed care. In 1998-99, he was the Rock Carling Fellow of the Nuffield Trust in London and also Visiting Professor at the London School of Hygene and Tropical Medicine, and Visiting Fellow at New College, Oxford. He wrote the Rock Carling Lecture In Pursuit of an Improving National Health Service, recommending further introduction of market forces in the National Health Service. He and Laura Tollen recently edited the book Toward a 21st Century Health System: The Contributions and Promise of Prepaid Group Practice. From 2005-2007 he served as project director for the CED and project director of the CED and report Quality, Affordable Healthcare for All: Moving Beyond the Employer-Based Health Insurance System, published in 2007.

Currently he is Marriner S. Eccles Professor of Public and Private Management, Emeritus, at Stanford Graduate School of Business.

Academic Degrees
Dr. Public Policy (Hon), RAND Graduate School, 2008; PhD, M.I.T., 1956; MPhil, Oxford University, 1954; BA, Stanford University, 1952.

Professional Experience
At Stanford since 1973.

• Chairman of Stanford Committee on Faculty/Staff Human Resources, 2004-Present;
• Rock Carling Fellow, Nuffield Trust, London, 1999;
• Visiting Professor, London School of Hygiene and Tropical Medicine 1998-99;
• Visiting Professor, University of Paris, and Visiting Fellow, St. Catherine’s College, Oxford University, Spring 1985;
• President, Litton Medical Products, 1971-73;
• Vice President for Economic Planning, Litton Industries, 1969-71;
• Assistant Secretary of Defense for Systems Analysis, 1965-69;
• Deputy Comptroller and Deputy Assistant Secretary of Defense, U.S. Department of Defense, 1961-65;
• Instructor, M.I.T., 1955-56;
• Economist, RAND Corp., 1956-60.

Selected Publications

• ‘Redefining Health Care’: Medical Homes or Archipelagos to Navigate?, with S. Shortell and F.J. Crossen: Health Affairs, 2007
• Competition in Health Care: It takes Systems to Pursue Quality and Efficiency, with Laura Tollen: Health Affairs, 2005
• Toward a 21st Century Health System: The Contributions and Promise of Prepaid Group Practice, Jossey-Bass, 2004
• Managed Competition: History and Principles: Health Affairs, supplement 24-48, 1993
• Employment-Based Health Insurance is Failing: Now What?: Health Affairs, Web Exclusives, 2003

Working Papers

• 1023: A Consumer Choice Health Plan For The 1990s: Cost And Budget Estimates And Supporting Detail
• 1292: Health Plan Purchasing Cooperatives (HPPCs) and Reform of The Small Group Health Insurance Market
• 1411: Reforming Medicare Before It’s Too Late
• 751: Will the Prospective Payment System Solve Medicare’s Financial Problem?

Awards and Honors

• Director’s Award, 1995, Health Care Financial Management Association
• Winner of the Baxter Prize for Health Services Research, 1994
• Clifton Latiolais Honor Medal, 1994
• President’s John F. Kennedy Award for Distinguished Federal Civilian Service, 1963, U.S. Federal Government

Affiliations

• Advisory Board: External Health, 2007-present
• Board of Directors: Caresoft Inc. (1998 – 2001)
• Board of Directors: Integrated Healthcare Association
• Board of Directors: PCS Inc., 1986-90; Jackson Hole Group, 1992-98
• Consultant: Kaiser Foundation Health Plan, 1973- present

Press Releases

• 07/2001 Stanford Health Policy Experts Offer New Health Insurance Proposal
• 11/2000 The Chronic Search for A Health Care Cure
• 11/1999 Managed Care: What Went Wrong? Can It Be Fixed?
• 06/1997 Alain Enthoven named to California’s Managed Health Care Improvement Task Force
• 03/1997 Managed Care for Medicare

In the News

• 04/2003 Cutting-edge Health Care Lagging, The Argus
• 01/2002 Group Promotes Its Health Agenda, Los Angeles Times
• 12/2001 Aetna Plans to Cut 6,000 More Jobs, Los Angeles Times
• 11/2001 Fewer Choices for Workers on Benefits, New York Times
• 06/2000 Pitching Health Care for All Kids, San Jose Mercury

Contact – enthoven@stanford.edu

• Alain C. Enthoven bio from Stanford University
• http://www.keyspeakers.com/bio.php?Alain_Enthoven

Milton Friedman

მილტონ ფრიდმანი – Milton Friedman (1912 – 2006)

Milton Friedman

Milton Friedman

Milton Friedman & President Reagan

Milton Friedman & George Walker Bush

Milton Friedman

Milton Friedman. 1981, San Francisco, California, USA

ლუდვიგ ფონ მიზესი - Ludwig von Mises

ლუდვიგ ფონ მიზესი – Ludwig von Mises (1881-1973)

Людвиг фон Мизес – “Экономические причины войн”

Война – один из древнейших институтов человечества. С незапамятных времен люди с готовностью сражались между собой, убивали и грабили друг друга. Однако признание этого факта не означает, что война – необходимая форма отношений между людьми и попытки исключить ее из нашей жизни противоречат человеческой природе, а потому обречены на неудачу.

В полемических целях мы можем признать правоту милитаристского тезиса о том, что человеку по определению присущ инстинкт убийства и уничтожения. Однако характерными чертами человека являются не эти примитивные инстинкты и импульсы. Он стоит выше других живых существ потому, что обладает разумом и способностью к абстрактному мышлению. И разум подсказывает человеку, что мирное сотрудничество и взаимодействие на основе разделения труда выгоднее, чем вражда и насилие.

Не стану останавливаться на истории войн. Достаточно будет отметить, что в XVIII веке, на пороге современной капиталистической эпохи, характер войны был уже не таким, как во времена варварства. Люди больше не сражались друг с другом ради истребления или порабощения побежденных. Войны стали одним из инструментов политики и велись сравнительно немногочисленными профессиональными армиями, в основном состоявшими из наемных солдат. В ходе войн определялось, какая династия будет править той или иной страной или провинцией. Крупнейшие вооруженные конфликты в Европе XVIII века представляли собой войны за престолонаследие – за испанское, польское, австрийское и, наконец, баварское наследство. Для простых людей исход этих противоборств особого значения не имел. Их не слишком волновало, кто будет их сюзереном – Габсбурги или Бурбоны.

Тем не менее эти конфликты были тяжелым бременем для человечества. Они представляли собой серьезное препятствие на пути к росту экономического благосостояния. В результате философы и экономисты того времени начали уделять внимание причинам войн. Эти изыскания привели их к следующему выводу: в условиях частной собственности на средства производства и частного предпринимательства, когда единственная функция государства – это защита граждан от насильственных или мошеннических посягательств, жителям любой страны безразлично, где именно проходят ее границы. Никого не заботит, велика или мала их страна, завоюет она ту или иную провинцию, или нет. Простым гражданам захват территорий не приносит никакой выгоды.

Однако с точки зрения монархов и правящего класса аристократов все выглядит по-иному. Расширение территории владений позволяет им усилить собственное влияние и увеличить налоговые поступления. Завоевания им выгодны. Поэтому если простые граждане миролюбивы, то те – воинственны.

Таким образом, утверждали классики-либералы, избежать войн позволит система, где в экономике царит принцип laissez faire, а в политике – народовластие. Войны уйдут в прошлое, ведь для них не будет больше причин. Поскольку либералы XVIII-XIX столетий были убеждены, что переходу к экономической свободе и политической демократии ничто помешать не может, они с уверенностью утверждали: человечество стоит на пороге эры вечного мира.

Чтобы мир во всем мире стал реальностью, отмечали они, необходимо утверждение экономической свободы, свободной торговли и отношений доброй воли между народами, а также народовластия. Хотел бы подчеркнуть важность обоих этих условий: свободы внутренней и международной торговли и демократии. Роковая ошибка нашей эпохи заключается в том, что мы отказались от первого из этих условий – а именно, свободной торговли – и делаем акцент только на политической демократии. Тем самым люди игнорируют тот факт, что без свободы предпринимательства, торговли и экономической свободы демократия тоже не может сохраняться надолго.

Президент Вудро Вильсон был абсолютно убежден, что для обеспечения мира во всем мире необходимо, чтобы в нем восторжествовала демократия. В годы Первой мировой войны считалось: чтобы наступил прочный мир, достаточно отстранить от власти германскую правящую династию Гогенцоллернов и поземельное дворянство (юнкерство). Вильсон не понимал, что в ситуации растущего всесилия государства этого будет недостаточно. В мире, где полномочия государства постоянно расширяются, у войн появляются экономические причины.

Выгодны ли простым гражданам завоевательные войны?

Видный британский пацифист сэр Норман Энджелл (Angell) не устает повторять: отдельный гражданин ничего не выигрывает от захвата его страной чужих территорий. Ни один простой немец, утверждает он, не получил никакой выгоды от присоединения к Германской империи Эльзаса и Лотарингии в результате Франко-прусской войны 1870-1871 годов. Это абсолютно верно. Но так выглядела ситуация во времена классического либерализма и свободы предпринимательства. В наши дни, когда государство активно вмешивается в экономику, все изменилось.

Приведем пример: правительства стран, производящих натуральный каучук, заключили картельное соглашение, чтобы создать монополию в этой области. Они вынудили плантаторов ограничить производство, чтобы цены на каучук намного превысили уровень, существующий в условиях свободного рынка. И это отнюдь не исключение. Объектом такой же политики со стороны правительств разных стран стал целый ряд важнейших продуктов питания и видов сырья. Во многих отраслях промышленности государства осуществляют принудительную картелизацию, в результате чего контроль над соответствующими предприятиями переходит от частных предпринимателей в руки правительства. Конечно, некоторые из таких шагов завершились провалом. Но подобный результат не побудил государства отказаться от своих планов. Они стараются усовершенствовать применяемые методы и уверены, что после окончания нынешней – Второй мировой – войны их новая попытка увенчается успехом.

Сегодня много говорится о необходимости планирования на международном уровне. Однако, чтобы плантаторы выращивали каучук, кофе и др. никакого планирования, ни в национальном, ни в международном масштабе, не нужно. Они производят эти товары, потому что это для них – наилучший способ заработать на жизнь. Планирование в данном случае неизменно означает действия государства по ограничению производства и установлению монопольных цен.

В этих условиях уже нельзя говорить о том, что народ не получает никаких конкретных выгод от победоносной войны. Если государства, зависящие от импорта каучука, кофе, олова, какао и других сырьевых товаров, вынуждают правительства стран-производителей отказаться от монополистической политики, они улучшают тем самым материальное положение своих граждан.

Подобная оценка ситуации, конечно, не оправдывает агрессии и завоеваний. Она лишь демонстрирует, насколько ошибаются пацифисты вроде сэра Нормана Энджелла, исходя в своих аргументах в пользу мира из допущения, что все страны по-прежнему сохраняют приверженность принципам свободного предпринимательства.

Сэр Норман – член Лейбористской партии Великобритании. Эта партия выступает за прямое обобществление экономики. Однако лейбористам не хватает проницательности, чтобы понять, какими политическими последствиями это обернется.

Пример Германии

Объяснить суть этих последствий я хотел бы на примере ситуации в Германии.

Как и все другие страны Европы, Германия небогата природными ресурсами. Их недостаточно, чтобы прокормить и одеть ее население. Германия вынуждена импортировать сырье и продовольствие в больших объемах и оплачивать этот необходимый импорт за счет экспорта промышленной продукции, большая часть которой производится с использованием импортного сырья. В условиях свободы предпринимательства немцы блестяще приспособились к этой ситуации. Шестьдесят – семьдесят лет назад, в 1870-1880-х годах, Германия по экономическому благосостоянию занимала одно из первых мест в мире. Ее предприниматели сумели создать чрезвычайно эффективные промышленные предприятия. По объему промышленного производства страна занимала первое место в Европе. Немецкие товары триумфально завоевывали мировой рынок. Благосостояние немцев – всех классов населения – росло с каждым годом. Никаких оснований для изменения структуры германской экономики не существовало.

Однако большинству немецких идеологов и политических публицистов, профессоров, получавших жалованье от государства, лидеров социалистической партии и госчиновников рыночная экономика не нравилась. Они клеймили ее, называя «капиталистической», «плутократической», «буржуазной», «западной» и «еврейской». Они сетовали по поводу того, что свобода предпринимательства привела к интеграции Германии в систему международного разделения труда.

Все эти группы и политические партии стремились заменить свободное предпринимательство системой государственного управления бизнесом. Они хотели покончить с таким мотивом экономической деятельности, как получение прибыли. Они выступали за национализацию бизнеса и его подчинение указаниям властей. В стране, в целом обладающей экономической «самодостаточностью», сделать это сравнительно просто. Россия, занимающая шестую часть суши, может обходиться практически без импорта. Однако с Германией дело обстоит по-иному. Она не может отказаться от импорта, а потому ей необходимо экспортировать промышленные товары. Но обеспечить такой экспорт государственная бюрократия не в состоянии. Чиновничество может править бал лишь в условиях закрытости внутреннего рынка. Вести конкурентную борьбу на зарубежных рынках оно не способно.

Сегодня большинство населения нацистской Германии хочет, чтобы государство контролировало бизнес. Однако государственный контроль над экономикой и успешная внешнеторговая деятельность – вещи несовместимые. Социалистическое государство должно стремиться к экономической автаркии. И здесь в дело вступает агрессивный национализм, прежде называвшийся пангерманизмом, а ныне – национал-социализмом. Мы могучая нация, говорят национал-социалисты, нам по силам сокрушить все другие народы. Нам необходимо завоевать все страны, обладающие ресурсами, необходимыми для нашего экономического процветания. Нам нужна автаркия, а чтобы достичь ее, надо воевать. Нам нужен Lebensraum (жизненное пространство) и Nahrungs freiheit (продовольственная независимость).

Оба эти понятия означают одно и то же – завоевание территории настолько обширной и богатой природными ресурсами, что в результате немцы смогут и без внешней торговли обеспечивать себе такой же жизненный уровень, как у граждан любой самой богатой страны. Термин Lebensraum хорошо известен за пределами Германии. Иначе обстоит дело с Nahrungs freiheit. Freiheit – это свобода; Nahrungs freiheit – это в буквальном переводе «свобода от ситуации, при которой Германия должна импортировать продукты питания». В глазах нацистов только такая «свобода» имеет ценность.

Коммунисты и нацисты едины в одном: суть того, что они подразумевают под демократией, свободой и народовластием – это установление полного контроля государства над экономикой. И неважно, какое название дается этой системе – социализм, коммунизм или плановое хозяйство. Как ее ни назови, эта система требует экономической автаркии. Но если Россия в целом ею обладает, то у Германии такой возможности нет. Поэтому социалистическая Германия должна проводить политику завоевания Lebensraum или Nahrungs freiheit, т.е. политику агрессии.

Конечным результатом программы по установлению контроля государства над бизнесом является отказ от участия в международном разделении труда. Согласно нацистской философии, единственный подходящий режим международных отношений – это война. Их лидеры с гордостью цитируют римского историка Тацита, заметившего две тысячи лет назад: германцы считают постыдным приобретать упорным трудом то, что можно приобрести мечом. И кайзер Вильгельм II в 1900 году отнюдь не случайно призвал своих солдат брать пример с гуннов. Его слова были образным изложением осознанного политического курса.

Зависимость от импорта

Германия – не единственная европейская страна, зависящая от импорта. Население Европы – без России – составляет 400 миллионов человек: это в три с лишним раза больше населения Соединенных Штатов. Однако Европа не производит хлопок, каучук, копру, кофе, чай, джут, там нет месторождений многих важнейших металлов. Кроме того, она не в состоянии полностью обеспечить себя шерстью, фуражом, скотом, мясом, кожей и многими видами зерновых.

В 1937 году в Европе было добыто всего 56 миллионов баррелей сырой нефти (для сравнения, в том же году нефтедобыча США составила 1279 миллионов баррелей). Более того, почти вся нефть в Европе добывалась в Румынии и на востоке Польши. Однако по итогам нынешней войны эти территории окажутся под контролем России. Основу европейской экономики составляет производство и экспорт промышленной продукции. Но в условиях государственного контроля над бизнесом такой экспорт практически невозможен.

Таковы упрямые факты, и никакая социалистическая риторика их не изменит. Для выживания европейцы должны полагаться на проверенные механизмы свободного предпринимательства. Альтернатива – война и завоевания. Немцы дважды пошли по этому пути, и оба раза он привел их к неудаче.

Однако наиболее влиятельные в политическом отношении группы в Европе не осознают необходимости экономической свободы. В Великобритании, Франции, Италии и некоторых малых странах ведется мощная агитация в пользу полного контроля государства над бизнесом. Правительства этих стран практически глухи к аргументам об экономической свободе. Британская Лейбористская партия и те английские политики, что до сих пор, но уже без каких-либо оснований, называют свою партию Либеральной, рассматривают нынешнюю войну не только как защиту независимости своей страны, но и как возможность осуществить настоящую революцию в области контроля государства над экономикой. Третья британская партия – Консервативная – также в общем и целом сочувствует этим планам. Британцы хотят победить Гитлера, и в то же время жаждут применить его экономические методы в собственной стране. Они не подозревают, что государственный социализм в Великобритании обрекает ее население на печальную участь. Чтобы закупать за рубежом сырье и продовольствие, Британия должна экспортировать промышленную продукцию. И любое сокращение этого экспорта негативно отразится на жизненном уровне основной массы британцев.

Во Франции, Италии и большинстве других стран Европы существуют те же условия, что и в Британии.

В деле обеспечения отечественного потребителя тем, что ему необходимо, социалистическое государство диктует свою волю. Гражданин вынужден брать то, что оно ему дает. Но во внешней торговле все обстоит не так. Иностранный потребитель купит товар только в том случае, если будет удовлетворен его качеством и ценой. На этой международной арене обслуживания зарубежных потребителей капитализм демонстрирует большую эффективность и гибкость. Высокий уровень благосостояния и цивилизации в Европе в довоенный период не был результатом деятельности правительственных ведомств и структур. Все эти немецкие фотоаппараты и химикалии, британские ткани, парижские платья, шляпки и духи, швейцарские часы, венские кожаные сумки были изготовлены не на контролируемых государством предприятиях. Их производство организовали предприниматели, неустанно работавшие над улучшением качества и снижением цены своей продукции. Ни один разумный человек не скажет, что в этом плане государственное ведомство способно с успехом заменить частного предпринимателя.

Когда международную торговлю ведут частные предприниматели, речь идет о частном деле частных фирм из разных стран. Соответственно, возникающие разногласия представляют собой конфликты между частными компаниями, не влияющие на политические отношения соответствующих государств. Они касаются лишь герра Майера и мистера Смита. Но когда внешнюю торговлю берет в свои руки государство, эти конфликты превращаются в политические проблемы.

Представим, что голландское правительство предпочитает закупать уголь в Великобритании, а не в германском Руре. В этом случае у германских националистов может возникнуть мысль: «Почему мы должны терпеть такое поведение малой страны? В 1940 году Третьему рейху хватило четырех дней, чтобы разгромить голландские вооруженные силы. Надо проделать это еще раз, и тогда мы получим все, что производят Нидерланды, причем совершенно бесплатно!»

«Справедливое» распределение ресурсов

Давайте рассмотрим известное требование нацистских и фашистских агрессоров о новой, более «справедливой» системе распределения сырьевых ресурсов в мировом масштабе. В условиях свободного предпринимательства любитель кофе, не являющийся владельцем кофейной плантации, должен за него заплатить. Неважно, где он живет – в Германии, Италии, или даже Колумбии: ему необходимо оказать те или иные услуги своим соотечественникам, заработать деньги и отдать их часть за любимый напиток. Если же речь идет о стране, где не выращивают кофе, то ей приходится экспортировать сырье или товары, чтобы оплатить его импорт. Однако Гитлера и Муссолини такое решение проблемы не устраивает. Их рецепт – аннексия страны, где выращивают кофе. Но поскольку граждане Колумбии и Бразилии без энтузиазма относятся к перспективе рабства у германских нацистов или итальянских фашистов, речь идет о войне.

Другой нагляднейший пример – ситуация с хлопком. Более ста лет одной из важнейших отраслей промышленности в Европе была переработка хлопка и изготовление из него текстильных изделий. В самой Европе, как известно, хлопок не выращивают: климат не подходит. Однако ей всегда удавалось импортировать его в нужном объеме – единственным исключением стал период Гражданской войны в США, которая привела к перебою с поставками из южных штатов. Промышленно развитые страны Европы получали достаточно хлопка не только для удовлетворения собственных потребностей, но и для значительного экспорта хлопчатобумажных изделий.

Однако в последние годы перед началом Второй мировой войны ситуация изменилась. Предложение хлопка-сырца на мировом рынке осталось на прежнем уровне. Однако система валютного контроля, введенная в большинстве европейских государств, не позволяла частным бизнесменам закупать его в нужном количестве для своих производственных нужд. При Гитлере немецкая хлопчатобумажная промышленность пришла в упадок, поскольку он ограничил объемы производства и заставил предпринимателей уволить значительную часть рабочих. Над судьбой этих людей, лишившихся работы, Гитлер особо не задумывался – он отправил их трудиться на военные заводы.

Как я уже отмечал, в условиях свободы торговли и предпринимательства экономических причин для вооруженной агрессии не существует: отдельные граждане не извлекают никаких преимуществ из захвата той или иной провинции или колонии. Однако в мире, где существуют тоталитарные государства, у многих людей возникает убежденность в том, что в результате аннексии какой-либо территории, богатой природными ресурсами, их материальное благосостояние возрастет. Войны XX столетия, несомненно, обусловлены экономическими причинами. Однако они порождены не капитализмом, как пытаются нас уверить социалисты. Происхождение этих войн связано со стремлением государств обрести полное политическое и экономическое всемогущество, поддерживаемым введенной в заблуждение основной массой населения соответствующих стран.

В нынешней войне три главных агрессора – нацистская Германия, фашистская Италия и имперская Япония – не добьются своих целей. Они уже потерпели поражение, и сами это сознают. Однако в будущем они могут предпринять новую попытку, поскольку их ложная тоталитарная идеология не знает иных методов улучшения материальных условий жизни населения, кроме войны. Для тоталитаристов завоевание – единственный действенный политический способ достижения экономических целей.

Экономическое мышление

Я не хочу сказать, что все войны в истории были обусловлены экономическими соображениями, т.е. стремлением агрессора обогатиться за счет побежденных. Но в рамках настоящего анализа нет необходимости изучать первопричины, скажем, Крестовых походов или религиозных войн XVI-XVII столетий. Ведь я имею в виду другое: в наше время все большие войны были результатом определенного экономического мышления.

Вторую мировую войну определенно нельзя назвать конфликтом между белой и цветными расами. Между британцами, голландцами, норвежцами и немцами нет никаких расовых различий; то же самое можно сказать о французах и итальянцах или китайцах и японцах. Это также не война между католиками и протестантами: и тех и других можно встретить в обоих противоборствующих лагерях. О борьбе между демократией и диктатурой тоже говорить не приходится. Претензии нескольких стран, входящих в Объединенные нации (в частности Советской России), на звание «демократических» выглядят весьма спорными. С другой стороны Финляндия (союзница нацистской Германии) – это страна с демократической выборной властью.

Мой аргумент о том, что движущей силой последних войн стали экономические соображения, не оправдывает агрессоров. Политика агрессии и захватов, рассматриваемая как средство достижения тех или иных экономических выгод, обречена на неудачу. Даже если в краткосрочном плане она увенчается «техническим» успехом, в конечном итоге цели агрессоров не будут достигнуты. В современную промышленную эпоху создание социальной системы, которую нацисты называют «новым порядком», исключено. Рабство для промышленно развитого опыта – не метод. Если бы нацисты победили своих противников, это означало бы разрушение цивилизации и возврат к варварству. Что бы ни обещал Гитлер, создать Тысячелетний Рейх на основе «нового порядка» им бы точно не удалось.

Таким образом, главный вопрос заключается в том, как избежать новых войн. И ответом на него станет не создание улучшенного варианта Лиги наций, или усовершенствование Международного суда, или даже учреждение всемирных полицейских сил. Подлинная задача заключается в том, чтобы все страны – или по крайней мере страны с наибольшей численностью населения – обрели миролюбие. А достичь этого можно лишь одним способом: вернувшись к свободе предпринимательства.

Если мы хотим исключить из нашей жизни войны, необходимо устранить их причины.

Главным «идолом» нашей эпохи стало Государство. Государство – необходимый для общества институт, но обожествлять его нельзя. Оно не бог, а механизм, созданный простыми смертными. Поклоняясь ему, мы вынуждены будем приносить в жертву этому идолу цвет нашей молодежи, обреченный на гибель в будущих войнах.

Чтобы обеспечить прочный мир, мало построить новую штаб-квартиру для Лиги наций в Женеве, и даже создать международные полицейские силы. Нужно изменить политическую идеологию и вернуть экономическую систему, покоящуюся на прочной основе свободного рынка.

http://www.inliberty.ru/library/classic/1904/