Convicts and Convictions: Some Lessons from Transportation for Health Reform

Abstract:     
The Patient Protection and Affordable Care Act (PPACA) is a Rorschach test. To its enthusiasts, PPACA is a historic transformation that will dramatically broaden access, lower costs, reduce the deficit, and eliminate health care fraud, waste, and abuse. To its critics on the right, PPACA is a catastrophically misguided, ineffective, and unaffordable monstrosity, crammed down the throats of an unwilling public by special deals and legislative chicanery. To its critics on the left, PPACA is a disappointment of epic proportions; with control of the presidency and the House and a filibuster-proof majority in the Senate, the Democrats couldn’t even deliver a public "option," let alone a single payer.

PPACA has given rise to a massive amount of commentary - much of it devoted to an in-depth explication of why the writer’s interpretation of PPACA (almost always chosen from one of the three options offered above) is the "correct" one. This Article focuses instead on lessons that reformers should have learned from transportation if they had actually wanted to reform the American health care system. The transportation of convicts from Britain and Ireland to America and Australia between 1718 and 1868 provides a case study of the importance of three "I"s - incentives, institutions, and individuals - to the observed mortality patterns. The article connects these issues to several fundamental design defects in PPACA, and then explores the importance of three additional "I"s - ignorance, incompetence, and ideology - in the design and implementation of PPACA. It concludes by considering whether PPACA is sustainable, even taken on its own terms.

Number of Pages in PDF File: 45

Keywords: Health reform, PPACA, incentives, institutions

JEL Classification: I11, J32, K32

Accepted Paper Series