Dangerous Dan Thoughts and musings on the world

3/23/2010

Healthcare Thoughts

Filed under: General — Dangerous Dan @ 5:09 pm

(Note – This was written prior to the passing of the bill)

The current health care reform proposals from the Democrats are simply bad. If nothing else, it asks the American people to engage in a massive suspension of disbelief. Obama, Pelosi, Reid, and the rest claim that the reform will cover more people, cut health care costs, cut insurance premium costs, reduce demand and not ration, improve care, increase choice and competition, and cut the deficit. They may as well add how the plan will benefit the unicorn population and that it will be funded with rainbow-terminus leprechaun gold. It is impossible for any plan, especially this one, to do all those things and in the positive manner people suppose. We're being asked to believe a fairy tale long enough for the opening pages to get passed into law and once that's done, we'll be unable to close the book before the tale turns from Disney to Grimm.

Let's handle the contentions one by one, but first some groundwork.

You may never have considered it, but health care and health insurance in the U.S. are pretty bizarre. The operate like no other segment of the economy.

Unlike pretty much every other type of insurance (save maybe life insurance), you get health insurance through your employer. Why? Why not also get your employer to pay for your car insurance, renter's insurance, homeowner's insurance, maybe insure your collection of Star Wars figurines? The reason the majority of Americans get it through their employer is because of history and previous/current government policies. Back in World War II, there were wage and price freezes in effect (by Federal fiat). This created a problem for businesses that wanted to attract qualified personnel because they would normally compete for labor by using wages. With the wage freeze, however, that wasn't an option and they had to come up with something else they could use to compete for labor and that was health benefits. It became popular enough that the tax code was changed to accommodate it, but the change also encouraged it. For employers, money spent on providing health insurance premiums to employees is a tax deductible business expense. For employees, the income they receive as health benefits is considered non-taxable income. The same tax courtesies are not extended to the individual market. If I want to buy an individual policy from an insurance company, I must do so with after-tax dollars. Thus, employers have an incentive to provide health insurance to its employees and employees have an incentive to expect and demand it from their employers.

The way health insurance operates is also quite odd. Think for a moment about the last time you went to the doctor. Now… how much did it cost? Likely, the amount you thought of was your copay, probably somewhere around $5-$50 depending on your plan. But that's not how much it cost, that's only how much you had to pay and it will be the same every time, no matter what you go in for or for what treatment you receive. How much did the appointment cost overall? If you don't know, you've stumbled upon the giant problem with health insurance and health care costs in this country. Try to name any other good or service that you consume for which you don't know the price before, during, or after you consume it. I'll be surprised if you can think of any.

The difficulty is that unlike other types of insurance that cover large damages while you cover regular costs and maintenance costs, health insurance covers nearly all the costs. You don't pay a $5 copay when getting your oil changed while Geico picks up the rest, for example. But let's say it did. Would you care about the price of the oil change before you got it? Would you bother to get the prices of oil changes at different shops? Would you demand the oil of sufficient quality or would you want the best synthetic available? Would you go with just the oil change you need or also have them do other work while you're at it? Therein lies the problem. One great absolute truth is that you will always spend your own money more wisely than you will spend somebody's else's. And in the case of health care, you're spending somebody's else's money, i.e. the insurance company's. As such, you have no incentive to price shop or to find out prices at all; no incentive not to get unnecessary procedures or treatments; no incentives to get cheaper medication that will work as well as more expensive ones, etc. You don't have these incentives because you're not spending your own money and so you don't care about prices. This makes health care a distorted market. Since you have no incentive to pay attention to prices, doctors don't compete on price like suppliers must in other markets. Providers can and will charge more because they can, not necessarily because they're greedy but they have no incentive to lower what's charged and given the way insurance and Medicare/Medicaid reimbursement schemes work, they have an incentive to charge more. They will also tend towards inefficiency without normal competitive market pressures and with having staff who solely deal with reimbursements.

If we observe health care segments where health insurance does not play a role, e.g. Lasik and cosmetic surgery, what we see is a reduction in prices, lots of competition, better service, and yet still better and more effective treatments. That's because in these segments, people are spending their own money and so they have a tremendous incentive to make sure their money is spent judiciously. So they compare prices, results, doctors, staff, etc., just like they would any other good or service they consume.

So let's go back to the Democratic health care reform and see if it can achieve the various things they claim its supporters claim it will.

1. Covering more people. This is probably the one believable part, though its necessity is vastly overstated. Supporters can't quite decide just how many millions of people don't have health insurance (and let's not conflate health insurance with health care as many are wont to do since lack of the former does not entail lack of the latter)… figures have ranged anywhere from 30 million Americans to nearly 50 million. When the group is examined, however, we discover that its population is not static. That is, it's not the same 30 million all the time. Some are illegal immigrants. Some are people who qualify (or their children do) for existing coverage, e.g. Medicaid, but they simply haven't signed up for the benefits. Some are folks who are between jobs and therefore between insurance plans. Some are healthy younger folks who could afford insurance, but, because they are young and healthy, have opted not to purchase it. Once those groups are accounted for, the number of consistently uninsured number closer to 10-15 million. A not insignificant number, but it's 5% of the population for which the other 95% will be heavily affected, not just in terms of how they receive health care, but also in other effects on the economy.

Given the structure of the reform and its compulsory requirement for purchasing insurance, this would also be an unfair restriction on people's freedom. The justification often given is that the young and uninsured are a risk to the system and drain it by not carrying coverage and so they must be required to have it. They must not be freeloaders. The real reason is that the system will need the young and healthy paying into the system and not using it or it will not be able to sustain older Americans who will be drawing from the it.

2. Cut health care costs. As we've covered, the biggest factor driving up health care costs is that people do not pay their own money for health care. The reform won't change this except to make it worse. People will be even more distant from the prices and costs of health care and they will naturally go up. Now it's true that the government, especially should it have firm control over the sector, can control costs, but it won't be through market systems. The control will come simply from the government dictating how much it will pay for various services, which is what it already does now to control costs in Medicare and Medicaid. The plans decide on their own how much they'll pay, regardless of how much it costs the doctor or how much she wants to charge. Many doctors either lose money or make rather little money on Medicare/aid patients, especially compared to privately insured patients. With an expanded government role in health care, we'll only see more of this. And the more private insurance is crowded out, the more it will reduce the incentive for doctors to stay in business or to provide superior care. Right now, Medicare/aid is tolerable to doctors and hospitals because they can still make respectable profits on the privately insured. Once that's taken away, however, there's nothing left.

3. Cut insurance premium costs. The long term idea for most liberal reformers is to get rid of private premiums altogether and shift to a government-only single payer system. For now, let's falsely assume they'll stop at what's currently being proposed. A cornerstone of their plan and what they keep touting is indeed popular, but still stupid. Laws would be enacted that would require companies to sell policies to those who have preexisting conditions and the cost of those policies would have to be the same or close to policies sold to those without preexisting conditions. Now this sounds nice and humane and nobody likes stories of poor individuals who couldn't get insurance because of some known or unknown health problem (though the occurrence of this is statistically far less than what many make it seem).

There is a reason insurance companies do this, however, and it's not because they're greedy and are trying to make mad profits (the average profit margin for health insurance is only about 2.2%, far less than many other industries). It's because they're trying to control costs: their's and, by extension, their customers'. If insurance companies are required to sell policies to the sick and at the same prices as to the healthy, the rational choice for consumers is simply not to carry coverage when healthy and only buy a policy when sick. This obviously can't work, though, since the insurance company would pay out far more money than is paid in and they will either have to raise their prices or go bankrupt. This is another reason the reform plan includes compulsory measures requiring people to always carry insurance. I imagine getting around this, however, won't be overly difficult and, at $1,500 to $4,000, or in other instances 2.5% of income, the proposed penalty for not carrying coverage is still less than cost of most policies… currently anyway. The typical government response to non-compliance of bad government policy is simply to increase penalties so as to force compliance. I imagine the current proposed penalties are just not to sound scary in order to aid passage, but they would quickly increase once full implementation is on. At least one Pelosi House draft indicated the possibility of $250,000 in criminal fines and five years in prison.

Additionally, the government would require certain base levels of coverage in policies allowed to be sold on the "market" exchanges, which, on average would be greater coverage than is often now the case. The more conditions, illnesses, procedures, etc., that must be covered, the greater the cost since there is greater chance of payout. Many states already have various requirements, with the greater coverage being more expensive. This is where straight-up politics will play a role. It will not matter whether people really need coverage for something or whether there are enough people to necessitate it. It will be up to politics. Let's say a small group of people suffering from condition X think their illness should be covered. They make a lot of noise and politicians cover it lest they be considered heartless and face voter wrath. Let's say some doctors come up with an expensive new procedure that isn't really any better than the older cheaper one, but they lobby the right pols and grease the right palms and it will be covered. Or let's say a newer, cheaper procedure is introduced by a startup company. The older, established, and very wealthy company that provides the older, expensive procedure greases the right palms to make sure the new version isn't covered, likely on some made up or inflated excuse of it being dangerous or not proven or some such. There will never be an incentive to strip away coverage, though. The only incentive will be to add coverage or prevent new coverage and along with that will come greater costs and premium prices.

Making the issue worse is a proposed Federal board that would review premium increases and determine whether or not the increases are justified. The board could even roll back increases it doesn't like. Again, though, the companies aren't doing this purely because they're jerks. The thing to bear in mind is that many increases are because A) of greater required coverage, but mostly B) health care costs keep increasing due to the reasons discussed. As health care costs increase, so do the costs to the insurance companies, and so must the price of the policies. It's a bit of a vicious cycle, really. Such a review board will technically have the ability to control health insurance costs to the consumer, but not to the companies or in general. If anything, they will increase the path toward insurance company bankruptcy. And, much like the required coverage, the board will not be guided by the reality of the marketplace or by the necessity of the company; it will be guided by politics. If a particular needed price hike proves to be unpopular with people (and what hike won't be?), the board will either prohibit it or significantly cut it back. Once more toward bankruptcy we go (which is a feature, not a bug for some since it advances us towards government dominance).

4. Reduce demand and not ration. This has got to be the most patently ridiculous assertions and anyone who says the reform will do either is lying or has absolutely no clue how economics works. If you increase the level of coverage, reduce copays, and trend toward a more single-payer system, you further distance people from any personal costs for their care. The more you disassemble pricing structures, the more people demand of something, not less. Lower personal costs equals greater demand. If you make something "free," you flatten out the demand curve and make demand nearly infinite.

And this leads us into why rationing will happen. Rationing will absolutely happen, though some supporters bizarrely claim it won't. It will happen for the very simple fact that everything is rationed. Rationing occurs for absolutely every resource, good, and service because there's no such thing as an infinite supply of anything. Everything is finite and because everything is finite and if there are people who want it, everything must be rationed in some way. This is the problem of scarcity that all economic systems try to solve: how to use finite resources in order to satisfy as many and as much of the nearly infinite wants of people. In a normal market system, rationing is done through prices. The more costly something is to do or produce or the rarer it is, the higher the price. The higher price means fewer people will demand it and so the item is effectively rationed. This occurs for everything from luxury yachts to a box of cereal. If you take away the pricing mechanism, demand becomes infinite since there's no reason NOT to want that thing, but supply remains finite. So without prices as our rationing mechanism, we must find some other method to ration our good. Our options are A) command, where the government makes all the determinations, but it couldn't fully get away with that here and probably couldn't manage it anyway; B) majority decides, which wouldn't work here; C) contests, and as much as I'd like to see a Running Man competition for seeing the doctor, that won't happen; D) equal shares, which won't work since people necessarily require unequal shares of health care; E) lottery, where the lucky get care; and F) first-come, first-served waiting lists.

The last two will be the rationing methods of choice. You laugh at the lottery method, but this is actually used in some smaller towns in Canada. A doctor comes around for a day once a week or once a month and those who get to see him are picked at random. But the waiting lists will be ubiquitous as they are in other, more socialized systems. Again, if you take away the price mechanism of rationing, it must be replaced with something else.

Imagine, if you will, the following scenario. Let's say we determine that people have the right to TV's. Because of this, people must be provided a television by the government at no cost (ostensibly) to the recipient. Because TV's are now "free," demand will skyrocket. Everyone wants a TV. It remains, however, that there are still only so many TV's to go around. So who receives a TV will be based on their place on the waiting list. Not only that, but people won't want just any TV. They will want the big screen, fancy flat screen HDTV's. While people can get them, the wait for these will be even longer since there are necessarily fewer of them. The TV's most readily available will be smaller, less complex sets. Indeed, since the government will want to satisfy as many people's wants for TV's as possible, they will focus funding on providing the smaller sets that will cost the system less money.

So it goes with health care. Waiting lists will become de rigueur for care and the lists will become longer due to the greater demand for care. The waiting lists for specialty care will be longest since people will have demand for them, but government will have focused spending on primary care since that's what most people will need and demand. This means that as long as you only require primary care, you will likely be satisfied with the system. As soon as something is actually, you know, really wrong with you, you will find yourself increasingly ill (or maybe just increasingly dead) as you must wait for specialty care that in a relatively freer market system is rather easy to come by. Canada and Great Britain are littered with cases of people waiting months for care that could be gotten in days in the U.S. Just getting what in America is same-day diagnostics, e.g. CT scan or MRI, can be a three week waiting period. The difference is that in a system that is more market-oriented, more expensive specialty care equals an opportunity for profit and providers therefore have an incentive to offer it as it's demanded by consumers. In the more socialized system, where funding comes more from government, the government has less of an incentive to provide this care as it is more costly and will be needed by fewer people. For it, specialty care is actually an inefficient use of resources when in the market system, it's efficient.

This form of rationing is not an unfortunate outcome of the proposal. It is a necessary outcome. Indeed, it really can't happen any other way.

But, you might say, don't health insurance companies already ration care? Yep, they do. They make determinations on whether certain care is appropriate in certain cases. Here's the thing, though. Despite the horror stories, insurance companies actually rarely reject care ordered by doctors. Certainly, out of cost control, they have to pay attention to things and they may prefer some treatments over others or that some are tried first, but they don't often deny care generally unless there is some kind of justification. And if you don't like your current company, you can always (though it may be costly) go with another company, another policy, etc., and you always have recourse to courts and the government. If, however, the government dominates the industry, you have far fewer options. It, after all, doesn't have infinite money (despite the apparent attitudes of some) and must also budget itself. It will also determine what care will be distributed. Only it will care less and you will have less recourse. It's hard to fight insurance companies. It's impossible to fight city hall.

The other aspect is that companies must provide certain care as obligated, and, because of the greater market freedom, will be able to provide it in a timely manner. Government, on the other hand, can change the rules of the game at will and will provide care less efficiently. Even many of the problems with the insurance companies will be alleviated with the reforms I'll get to. If we stick to the proposal itself (and not with the eventual government takeover), with certain mandated coverage and increasing medical costs, you will see less variation among the insurance companies, more tight-fistedness, and more restrictive rationing since they will seek ways to control costs other than premium increases that will be heavily regulated by the new review board. You will start seeing the very same government-dominated problems, e.g. less access to specialty care. This would likely be followed as justification for something akin to single payer and then it will become even worse.

5. Improve care. This won't happen. Remember that incentives matter. Take into consideration the incentives that providers will have in an increasingly regulated sector in which they will have less say in what they do. Among the ways insurance companies will try to control costs is through striking harder deals with providers, which will cut down on provider incentives to provide better or more costly care. Should the government dominate, it can determine its payments purely by fiat, which will be below profitable level for many doctors who will quit the field altogether or just scale back.

Another problem is taking into consideration the skimping on specialty care that will result from insurance companies and/or government plans. While the U.S. health care is made to seem terrible, it really isn't. Longevity statistics, for example, make it seem like we don't live as long as folks in other countries. And that's what they show, but they're skewed. Americans are far more likely to die at younger ages due to murder, car accidents, obesity, smoking related diseases, and a few other things that are not related at all to the quality or nature of the health care system. That skews our overall rate downward. Once those variables are accounted for, we come out as well or better than other countries. And that's longevity at birth. If you look at longevity at later ages, we come out much better. For example, a newborn male in 2005 would be expected to make it just shy of 75 years old (80 for women and overall average of 77.4). A 40 year old man in 2005, however, stood to make it to 77 (81 for women and overall average of 79.4). A 50 year old guy to 78 (82 for women and overall average of 80.4). At 60, it's 80 men, about 84 women, and overall average of 82. And this is for 2005. That same newborn when he's 40 in 2045 may have a greater life expectancy than his original 75.

Let's compare to France. In 2003, life expectancy at birth was about 80 years overall. For 40 year olds, it was 81. For 50 year olds, it was 82. And for 60 year olds, it was 83.

So at birth, Frenchies had 2.5 year advantage on us. At 40, it was 1.5 years. At 50, it was 1.5 years, and at 60, it was 1 year. The gap narrows at greater ages.

I feel kinda dirty even talking about longevity statistics since I'm not even confident they tell us anything overly informative about… well… any one thing. There are so many factors that go into longevity, e.g. health care, diet, genetics, lifestyles, crime, accidents, drugs, wild animal attacks, that it's nearly impossible to point to any one thing as being the primary determining factor and in all countries. Certainly, health care is a significant contributory factor, but given all the other possible factors that also apply, it's simply not possible to say that it alone makes the difference in, say, a 1 year difference in longevity between American and French 60 year olds.

We can, however, look at some stats where we can be slightly more confident in health care systems being primary factors. If you pay attention to five year survival rates for most cancers, for example, you are significantly more likely to be alive in the U.S. five years after diagnosis than you are in most other countries. For all cancers, 56% of European women will be alive in five years versus 63% of American women. For men, it's 47% Europe and 66% America. If you compare to, say, Great Britain and their government-run system, we come out even better since their survival rates are 53% women and 45% men.

Now this isn't to say that our system is perfect, doesn't need reform, and doesn't use money inefficiently. It's merely to say that other systems aren't necessarily better than ours in comparison nor ours worse. Also that you face some serious sacrificing of health care with more government control.

6. Increase choice and competition. Nope again. Adding a government option doesn't help competition. The problem is that government gets to make the rules and it can easily game the system in its favor. Not only that, but the government plan would be heavily subsidized which gives it a massive advantage in a marketplace as it can easily beat other plans on price.

Even without a public option, the other measures will destroy the competitive nature of the marketplace and force players out. You can't fix prices, make insurance companies cover expensive customers with preexisting conditions at the same prices as the healthy, and all the rest, decreasing the profit incentive of companies and expect them to remain. Some insurance companies are chomping at the bit for the reform because compelling people to buy insurance means more revenue. Other companies, however, have been smart enough to look past the short term gains and realize that greater government control of their industry will be bad for them in the long run.

There are some great ways to increase competition and choice, but, like most things, it involves less government action, not more and I'll discuss those options later.

7. Cut the deficit. I'm not sure that anybody really believes this one. Hell, even SNL has made fun of it. It's true the CBO said the deficit would go down, but it has to score based purely on what's written and the bills presented to it (at least the public ones since other drafts the Democrats had it score weren't made public) were full of all sorts of creative accounting shenanigans. For example, having ten years of revenue but only six years of spending, pulling money from Medicare, double counting money by crediting health care with money that's already designated for other government programs like Social Security, cutting payment amounts to doctors that Congress always includes in budgets only to negate it in later bills, and more. Credibility had to be strained on multiple fronts just to make it appear to work. If you've ever looked at government mandatory spending, however, it never goes down; it only goes up. With typical government efficiency, it will only get worse.

So, all told, I argue that none of the claimed benefits will obtain. They won't obtain individually and they certainly won't obtain in combination.

So what to do? Here are my proposals. New list!

1. Allow competition across state lines. Right now, you can only buy insurance in state. This automatically limits competition. It also means that residents of certain states (I'm looking at you, California!) must pay much more for their policies than resident of other states, often due to oppressive regulation and requirements by the state governments. Buying across state lines will increase competition not only among the companies but also among the states which will be forced to modify their regulations and requirements in such a way that it makes their companies competitive.

2. Either get rid of the fool tax policy incentivizing employer-based health insurance or extend it to individual policies. I don't want health insurance through my boss. I want my insurance to be a policy I own, that I directly pay for, and that I can take with me no matter what job I do or where I move. As it is, you have many people who might prefer to leave their job and do something else or even to start their own business, but they don't because they're afraid of losing their health insurance. Liberals agree that employer-based insurance isn't ideal, but their solution in greater government control is wrong. The real solution is a fairly simple matter of removing the overwhelming incentive for workers and bosses to want employer-based insurance.

The first option is to remove the tax privilege for employer insurance. If businesses can longer offer it as a tax deduction, they will be less likely to provide. For employees, if compensation as health benefits is taxable, they'll have no reason to want it from their employer. It would be better if the health benefits compensation is converted into wages and people can then buy policies on the open individual market just like any other type of insurance. The result would be much greater diversity and competition in the individual health insurance market. Right now, insurance companies do very little to compete for individuals since that's not where most people get their health insurance. They instead compete for companies. This in itself creates a conflict of interests in that the insurers must cater to and operate primarily in the interests of what the employers want and only tangentially what the consumers themselves want. When the insurers must compete directly for consumers, they must, like in any other market, offer a number of different types of policies catering to different preferences and at better prices in order to compete with other companies.

The second option is to extend the tax privileges to the individual market. With this, the money I spend on a individual policy would become non-taxable income (we could have a special 1099 form and everything). Employers could also provide a health benefits wage that would go directly to an insurer as would be a tax deduction for the business. Again, the incentive to have a policy through the employer is eliminated and the individual market is fostered.

3. Get rid of state-mandated required coverage items. I should have the opportunity to get the kind of coverage I want and not be forced into getting more than I need. Right now, both because of the state requirements and the fact that employers only offer a few policies that are one size fits all for their workforce, you're insured against any number of things that will not or are unlikely to be a problem for you. I, for example, am quite willing to forgo insurance for cervical cancer, getting my tubes tied, or for birth control pills. I am also willing to forgo coverage for diabetes, breast cancer, and STD's. While it's possible I could get one or more the last ones, due to my known history and behavior, I judge the chances of any of them befalling me to be sufficiently low that coverage for them is unnecessary. In the process, I am willing to accept the risk of non-coverage as well as the consequences should they happen to me.

The reason I want this is two-fold. First, it would make policies much cheaper for many people since they will have to be insured against fewer things. Second, it increases the competition that is possible within the market. With a wide variety of things that states require must be covered, you have reduced the possible product differentiation in the market and turned policies into less of a variable good and more into a standard commodity. This isn't in the consumers' best interest.

The down side is that policies for people who want or need certain conditions covered would be more expensive than plans with less coverage. This, however, is simply natural in any market. The more features you need or want, the more expensive it will be. And with insurance, the more you want to be insured against, thereby increasing chances of payouts, means you must pay more. This is just how insurance works and health insurance shouldn't be different. With a healthy individual market, even these plan prices will be better than in the current system.

4. Expand the role of Health Savings Accounts (HSA). This is a dandy idea that was started back in 2003. This allows you to deposit a potion of your wages into an account as non-taxable income. This money can then be used to pay for medical care and whatever is unspent in a given year will roll over, allowing you to accumulate funds. The money in the fund can then be used to pay for health care expenses. Why this is great is that consumers are suddenly spending their own money for health care. Because it's their own money, they will become much more concerned with the prices for care and will shop for what they judge to be the best use of their dollars. This in turn will encourage competition among providers who must now use price as a competitive factor. You will consequently see more efficient operations, better prices, better care, and more transparency. Many doctors would likely prefer being paid in this manner since it means they get paid immediate for services rendered instead of weeks for months wait between appointments and reimbursements from the government and insurance companies. It also means less paperwork and less staffing. That equates to greater efficiency and greater profits.

Ideally, I would like a solid HSA combined with a high deductible policy. Any ordinary health expenses would be paid out of the HSA (and heck, if enough is saved up, even unusual stuff, say, if a person really wants cosmetic surgery) and the insurance policy is still there for catastrophic coverage in case of serious injury or illness. The high deductible policy, especially on a healthy individual market, would be much cheaper than first dollar policies. So let's an HSA that can take $5,000 a year and a policy with a $5,000 deductible (or more if your finances can absorb the gap). That would be much better than the current system and create much greater responsibility among consumers who are increasingly insulated from costs and some of whom are beginning to think any kind of copay is too much.

What could be done then is raising the cap on how much can be contributed towards a plan in a given year. Money put into an HSA should also be allowed to be used to purchase a high-deductible policy, which is not now the case.

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