Four Question Interview with Mike Munger

I want freeforall to be a discussion. So, I thought I would have a series of four question interviews with a variety of persons from different perspectives. The rules of the interview are that I will pose the same four questions to different folks and publish their responses in full. You can get mad at me for stuff I write, but not for stuff others write.

First up is Mike Munger, chair of the political science department at Duke University, and the Libertarian Party candidate for Governor of North Carolina in 2008. Mike and I go way back...he taught me in graduate school at UNC his first semester as an assistant professor and we both survived. Mike is in Germany this summer.

Question 1. What is the biggest problem facing the U.S. health care system?

Sharply rising costs. Two ways to "solve" the costs problem: (a) give everyone insurance, so that they are insulated from cost increases. (b) reduce cost increases, and find ways to make basic health care cheaper.

(a) is the most talked about option, but it is a bad idea. Someone (the taxpayer) still pays for insurance, so we are not really protected from cost increases. The French economist, Frederic Bastiat, said that the state is the fiction that each of us should be supported by all of us. It may be that universal coverage for serious illness would protect people, but "free" health care is too expensive, unless we get a handle on costs.

Option (b) is much better, but harder, because medical lobbies and interest groups will fight it. The problem is that we do not teach, or reward, preventive action by citizens or basic primary care by physicians. NC has a big shortage in primary care, at every level.

Put it this way: I have auto insurance. But it does NOT pay for oil changes. If I don't do the oil changes, then the car will decline in value and break down. Nobody else has to pay for my bad decisions, and insurance won't cover the new engine if I ruined the old one by running without oil or maintenance.

Why should other people have to pay for the fact that I don't exercise, that I smoke, and that I eat a bad diet? "Free" insurance protects me against my own choices.

The answer is to lift restrictions on primary practice by Physicians Assistants and Nurse Practitioners. I'm not saying they should do annual check ups; we need docters, with broad training and experience, for that. But for many complaints, and for advice on diet and exercise, and smoking, even a simple computer based expert system can do a fine job. If I have a minor infection in my finger, or need my blood pressure checked, or want to know about the tingling in my diabetic toes, then I should be able to show up an office, without an appointment, and pay no more than $30 for the visit.

We can do this with oil changes, and it works fine! Why not with basic office visits? Right now, people delay going to primary care, or can't get an appointment. Then they have a REAL infection, or a stroke, or they have to have gangrenous toes removed at the emergency room.

Legalize health care. Allow PAs to practice basic primary care. And reduce the costs and hassle of going to the doctor. There is no reason it should be harder, or more expensive, than an oil change.

Question 2. What do you most want to see preserved about the U.S. health care system?

The US is the best in the world at designing new procedures for operations, and new protocols for physical therapy and prosthetics. That drive for innovation has to be preserved, whatever else we do.

Question 3. What is the most important health policy priority for North Carolina (or the USA)? [answer which ever you want to answer]

Reduce costs, and legalize basic primary care offered by Physicians' Assistants.

Question 4. If you could design a health system from scratch, what would it look like?


Universal private insurance, with large deductible. Very large amounts for total coverage, so that most major procedures are covered. People minimize basic health care costs by taking care of themselves, but the truly sick get taken care of by the system. Lots more competition, and many more providers, in primary care.

Our current system has it backwards: people want LOW deductibles (which is expensive), but then they often run out of benefits, or get cancelled, if they have a serious medical problem.


Mike Munger, in Germany