Marginal Revolution: The new Bush health care plan

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The new Bush health care plan

Jonathan Zasloff writes:

Bush plans to pay for it not by efficiencies, but rather by restricting the benefit packages of the already insured, through the deductibility cap. I'm sure that there are some extraordinarily lavish plans out there, but is there any serious policy justification for this way to go? If anything, this seems to be a recipe for business to delete coverage, and throwing more people into the individual market.

Paul Krugman is very negative. Arnold Kling loves the plan. Greg Mankiw isn't complaining. Ezra Klein says it is better than nothing.

My feelings are mixed, but my view is closest to Zasloff. In the short run the plan gives more coverage to the people who need it most, while avoiding the mistakes of recent state-level plans. That doesn't sound so bad. (By the way, has anyone serious done a study of subsidy incidence for health insurance tax credits?)

But I cannot side with Arnold Kling's view that third-party payment lies at the root of America's health care problem. Our tolerance for anxiety is sufficiently low that I expect the future to bring more and more insurance of many kinds, whether from the private sector or from government. The cost of this insurance, in terms of induced inefficiencies, will be high but a secure health care situation is one of the things in life that alone can make a difference between happiness and misery.

Furthermore given our "political irrationality" (my apologies to many readers, such as Matt and Ezra, but I am referring to your tendency, yes yours, to want national health insurance), there is a positive external benefit attached to private health insurance, above and beyond the gains to the insured. How far would the Democratic health care agenda get without "45 million uninsured"?

The goal is to get (virtually) everyone insured and keep them insured for as long as possible, and yes I know that eventually means health care at 20 percent of gdp and lots of people getting screwed out of just claims for reimbursement. It is simply the best we can do, and for that reason I don't want to tax private health plans.

The ambitious long-run program should be to restructure the insurance industry --through a judicious mix of regulation and deregulation -- to encourage competition across service quality rather than competition across cost-shifting. Frankly I have no idea how to do that but no one has ever convinced me it is impossible or utopian. We simply need better incentives for evaluating the performance of our insurance companies, and better ways of evaluating the performance of our doctors and hospitals. I'm not going to call that small potatoes, but compared to how health care has evolved since say 1920 it is not asking for the moon. That is one reason why I don't want to lock into total government control of the health care market for the next five generations or more.

In the shorter run, I expect medical tourism to continue to grow in importance, including possibly cruise ships.

Last week I had my first physical in twenty years, and it seemed no different from visiting a witch doctor who makes you feel better by shaking the rattle.

Posted by Tyler Cowen on January 23, 2007 at 08:06 AM in Medicine | Permalink

Comments

>>The goal is to get (virtually) everyone insured and keep
>>them insured for as long as possible

Isn't the goal to provide everyone with adequate health care? Insurance is just a means to an end.

Posted by: richard at Jan 23, 2007 8:31:50 AM

"to restructure the insurance industry"
I think the Carter Administration was thinking about that. We know what happened.

Posted by: lee at Jan 23, 2007 9:44:19 AM

Better means of evaluating doctors and insurance companies come with a better informed more knowledgeable consumer.

In the current system with the third party payer picking up the tab we really don't care or have the tendency to want the latest treatment instead of the one that gets the job done.

A more individually directed market would move us in that direction. If you are paying yourself you are more likely to be interested.

Posted by: Greg at Jan 23, 2007 10:01:19 AM

"Better means of evaluating doctors and insurance companies come with a better informed more knowledgeable consumer."

I just dont think this is true due to the complexity of modern health care. Take a look at the last line of Tylers post, and he is top 1% of the population smart AND interested in the world around him.

Posted by: mickslam at Jan 23, 2007 10:16:10 AM

"A more individually directed market would move us in that direction. If you are paying yourself you are more likely to be interested."

There's a point where ill health impedes or even prevents a person from being actively interested. If it's not obvious that neither you nor anyone else knows what that point is, then I'm guessing that you haven't had the pleasure of being seriously ill or injured.

The last time I was in the hospital for four days, the first three I was basically conscious but completely fried due to the medications and pain killers.

So I have to say fellas, get serious. Because this informed consumer in the hospital dogma is absurd.

Posted by: Russell L. Carter at Jan 23, 2007 10:30:31 AM

I think that any plan to extend coverage more widely needs to address the high costs of end of life and chronic care. Many studies have suggested that these types of expenditures account for a disproportionate part of the cost of health care in this country.

Prof. Cowen has previously recommended more free market reforms, which I also support. These would likely take out some of the preference for the latest (and most expensive) treatments when other more established (and cheaper) effective treatments are also available. HSA's are a good idea, and could eventually help middle and higher income families gain more control over expenditures, especially with deductible exemptions for medication for chronic conditions, as has been proposed.

I'm also somewhat pressed on the entirety of the Zasloff article. Tax credits for the uninsured might be a good idea, if it didn't cause companies to reduce benefits and create more uninsured. In reality, only large companies have "bargaining power", and the largest companies are effectively self-insured, only paying an insurer to administer the paperwork and negotiate with providers.

Limits on deductibility would need to be indexed to the overall cost of care, to have any chance of being fair, and not create another AMT debacle.

I would like to see Prof. Cowen get a little more specific on his prescription for "a judicious mix of regulation and deregulation".

Regards,

- Brian

Posted by: Brian G. Peterson at Jan 23, 2007 11:02:51 AM

Russell,

I tend to agree with you - in many states of health we are in no condition to be informed consumers. I recently had an experience with collapsing after a walk - and was hospitalized for two days. No way I was making decisions in that state.

It occurred to me upon my exit however that an innovative insurance plan might have enabled me to make SOME choices about my course of care before any such incident happened. Yes, it would be impossible to pre-plan for all, or even many, contingencies, but surely there are some general guidelines that could have been followed.

Tyler's recommendation about restructuring the insurance industry has political teeth. Many folks in my circle have an extreme distaste for insurance companies - claiming that they make huge profit margins while forcing providers to squeeze every last efficiency out of their people. Granted, the folks I know are on the provider side of things - and I have no idea what the real picture of the private insurers looks like.

What I'd like to see on the deregulation side is allowing health insurers to have an increased degree of flexibility in risk rating their pools, much like life insurance. Does it ever seem odd to people why it is OK for life insurance firms to come and give you a physical, draw blood, ask lots of questions about lifestyle and health choices, etc. before underwriting your policy, but that health insurers do not (are not permitted) to do the same? If this were allowed, then I would be in favor of having strong government programs for those "priced-out" of the risk pools, and programs to aid those that are too poor to purchase insurance on their own.

I'd also like to see a way for providers to receive bonuses, rather large ones, for demonstrating that they are getting good outcomes - controlling of course for the type of patients and illnesses that they attend to.

Posted by: Mike at Jan 23, 2007 11:12:11 AM

Tyler, what do you think about private v employer insurance? You say you don't agree with Kling that employer is (dramatically) worse, but do you agree with your quote of Zasloff that seems to say private is worse?

There is a big positive externality to insurance, or at least a big negative externality to the current situation: the poor use health care and don't pay for it. Maybe this is efficient, but it's definitely an externality.

Posted by: Douglas Knight at Jan 23, 2007 11:57:26 AM

I can't believe that an economist is arguing that health insurance should be subsidized for the wealthy.

Means test the health insurance tax break, make mortgage interest less deductible for the wealthy, and lower their tax rates (maybe make the top rate 28%). That's the argument I would expect from an economist.

Posted by: Buzzcut at Jan 23, 2007 12:13:53 PM

Third party payer is a big problem, but another one that is less frequently
noted (but not missed by economists like Arnold Kling), is the overly comprehensive
coverage of most health insurance plans. The purpose of insurance should be
to cover unforseen, catastrophic claims, like breaking a leg or getting a rare
disease. It should not cover every sniffle medication or even
routine check ups like Tyler just got.
Health insurance should also have large deductibles--like $5000-$10,000
per person per year.

Imagine what would happen to car insurance if your premiums covered routine lube and oil jobs, tire balancing, etc., and if it were paid for by your employer or the
taxpayers.

Posted by: Bill Stepp at Jan 23, 2007 12:39:30 PM

Mike writes:

"Yes, it would be impossible to pre-plan for all, or even many, contingencies, but surely there are some general guidelines that could have been followed."

Mike, I had never even heard of the extremely rapid skin infection that nearly did me in before the diagnosis in the emergency room. That's the only significant health care I've needed over the last 20 years. I am going to be nice here: it is simply infeasible to a priori know which, let alone choose from, the available therapies that might need to be applied before hand. I have five doctors in my immediate family, and they are not stupid people.

"If this were allowed, then I would be in favor of having strong government programs for those "priced-out" of the risk pools, and programs to aid those that are too poor to purchase insurance on their own."

It's already allowed. When I was launching a business I was rather surprised to learn that indivudual plan coverage for my family was denied by *all* providers in the great state of Arizona due to my previous episode of melanoma. Even through the alumni assocation pool of my graduate school!

I have come to detest personal anecdotage as a means of persuasion, but "right wing" economists are so far detached from reality that it turns out to be the most efficient approach.

Even Tyler, who I otherwise admire immensely, offers no arguments other than intuition, straight "from the gut":

"It is simply the best we can do, and for that reason I don't want to tax private health plans."

The fact of the matter is that there are other, more cost and health outcome effective systems in place in other countries, and their existence is proof that it's possible to do better than we do, or Tyler thinks we can do. And no, I don't think that psychological ruminations about base inclinations prove anything about what's possible.

Posted by: Russell L. Carter at Jan 23, 2007 1:14:25 PM

have you considered bush's proposal in the light of insurance industry product strategies

the proposal would re-structure the health financing system

it would burden the present employer-based system and accelerate it's demise

it would create conditions that would stimulate a "surge" in consumer directed health - savings accounts and high deductible insurance

Posted by: jamzo at Jan 23, 2007 1:28:00 PM

Anyone have any comments, pro or con, on the health system in Singapore? They have a public and private network. They force a 6-8% pre-tax savings rate for citizens to build their own accounts and be able to cover routine stuff. Under certain income levels, there is a tax credit to fund your medical savings account (I think). You buy the catastrophic insurance. You choose which health provider to use. While heavily subsidized, the public healthcare network still requires out-of-pocket expenses.

Posted by: Seth at Jan 23, 2007 1:39:26 PM

I think that the "bargaining power" of large companies (one of the main reasons supporters of employer-sponsored health insurance seem to support it) is overrated. In a truly free and open market, wouldn't competition be more effective in bringing down prices than bargaining power?

What if employers subsidized the cost of new cars for their employees, but then limited the choices of their employees to select models? I have a hard time believing that, under such a scenario, car prices would fall more quickly than under the current system.

Posted by: Christopher Monnier at Jan 23, 2007 1:52:53 PM

I think Ezra has looked more carefully at the Bush health plan and no longer likes it.

Posted by: Megan at Jan 23, 2007 2:28:30 PM

I would venture that Prof Cowen's relative bemusement at the health care industry is a function of relatively good health. Of course, should he or someone he loves come down with a chronic condition or medical emergency, then his attitudes towards informed vs captive consumers driving the market may change.

Furthermore, whatever benefits enjoyed by privately insured are functionally absent for the 45 million uninsured, and their marginalization by Prof Cowen either speaks to a mistaken belief that this either doesn't affect his health, his pocketbook, or simply a personal callousness.

Posted by: Nads at Jan 23, 2007 2:58:19 PM

Tyler, have you ever lived without health insurance? Even for one month? Ever??

Posted by: Kevin at Jan 23, 2007 3:15:40 PM

Nada is completely right. A good friend of mine had private insurance and was diagnosed with MS about a year and a half ago and I swear dealing with their insurance has been more problematic for them than the MS.

I probably considered myself an agnostic about the whole issue for a good while, but watching someone who actually needs proper health insurance be denied it, has convinced me how awful our current system is. I remember late last year a blogger from the Corner, I can't remember who, railing against our system because of their experience. Unfortunately, this is one of those issues that doesn't seem that bad just up until the time it smacks you in the face.

Posted by: Derrick at Jan 23, 2007 3:17:11 PM

I don't get it... in a universal health care system, why is insurance required. This post needs to be fast so maybe it'll be glib, but:

1) Insurance is a model where the company:
a) predicts a patient's costs;
b) charges them a little more than that but protects them against lower-probability, high costs, i.e. the consumer spends a little money to be secure against spending a lot of money.

2) This completely does not work for expensive diseases, because the expected costs is ludicrously high. We must subsidize these people. Insurance has nothing to do with this problem.

3) Universal health care means we don't care what people's expected costs are, because we will always pay the costs and they will always get the treatment (excepting --big caveat-- prioritization issues). Thus, insurance is not meaningfully related to universal health care. Expected costs are not relevant, we just pay the costs.

4) It seems pretty clear then, that private insurance companies per se have no logical role in universal health care.

5) However, HMO's or health plans could certainly have a role: coordinating coverage, prioritizing who gets coverage, etc. Government's role could be nothing more than subsidizing costs, so that no one is ever turned away from anything for lack of ability to pay.

6) Probably you do want people to have some "skin in the game", i.e. to have to pay a little more if they go for Cadillac-level health care, etc. So what you really want here is just a curve for every individual, where the market cost of the customer's coverage is the X axis and the post-subsidy cost to the consumer (including health-care-related taxes they pay) is the Y axis. You want this curve to have nice properties, e.g. monotonically increasing. The curve should also be drawn with respect to the individual's ability to pay. So everyone has skin in the game even if they are being subsidized.

7) I'm not sure how to deal with the "prioritization" issue, i.e. who gets lifesaving procedure/drug XYZ. But I am not sure that it should be left to who is willing to pay the most. It seems a little grisly.

8) On the other hand, the price signal does spur innovation.

Posted by: mk at Jan 23, 2007 4:17:26 PM

Tyler,

Why the quotes around 45 million uninsured? Is this figure inaccurate?

Posted by: Bernard Yomtov at Jan 23, 2007 4:17:29 PM

Let me just restate the most important bit more simply:

All we want to do here is broaden coverage with a subsidy. In particular, we want to draw a single, 3D curve that applies to all individuals:
X axis: Market cost of customer's health care this year
Y axis: Customer's income
Z axis: How much does customer pay the government in exchange for the government paying for all his health care.

We need to draw this 3D curve so that pretty much all people, even poor people, can reasonably afford health care (i.e. they get massively subsidized). Also we should probably ensure that people with the worst, most expensive diseases can definitely get covered.

The devil is in the details, of course. But this is the germ of an idea if nothing else. And this, I repeat my contention, has nothing to do with insurance, because there is no issue of predicting costs.

Posted by: mk at Jan 23, 2007 4:49:02 PM

Tyler writes: Tyler writes:

"The ambitious long-run program should be to restructure the insurance industry --through a judicious mix of regulation and deregulation -- to encourage competition across service quality rather than competition across cost-shifting. Frankly I have no idea how to do that but no one has ever convinced me it is impossible or utopian."

The experience with managed care provides insight into why this is so difficult. Enthoven and Ellwood's proposals for managed competition were intended to accomplish this, by encouraging groups of physicians and hospitals to organize into competitive plans that competed to offer the right mix of quality and cost. This vision was put in place by many employers in the 1980s and 1990s as companies began offering multiple options with competing plans and the company share of the premium fixed. Measured against the vision of Enthoven, or more modest expectations, this revolution failed and it is useful to understand why.

Companies and their employees pay a fixed premium for each of their employees and their families. Sick and healthy, the same amount. Over 80% of the typical company’s risk pool is healthy, and the amount a healthy person brings in as a premium is below their expected costs, i.e., these are the profitable enrollees. The healthy population puts a high premium on convenience, and minimizing disruption to their current relationship to a physician, regardless of how infrequently they go to the physician. The incentive for insurance companies under such arrangements is to expand their physician pools as widely as possible to attract the healthy, and they did so. Thus we wound up with competing plans with 80-90% of the physicians in a community in the panel.

The chronically sick are unprofitable patients, costing more than their premium, and the insurance companies and managed care plans had an incentive to discourage their enrollment or reenrollment by making specialty care and expensive services difficult to obtain. It is disputed how much this occurred, but the incentive is clear and as economists we assume incentives influence behavior.

Regardless, insurers compete for the healthy and try to serve their needs, not the needs of the sick.

A paper by Glazer and McGuire in the American Economic Review (2000), Optimal Risk Adjustment in Health Insurance Premiums: An Application to Managed Care, concluded that even actuarial fair premiums would encourage health plans to try to avoid poor risks, and that the optimal level of risk adjustment in premiums needed to neutralize this incentive would set premiums at more than the actuarially fair premium for the sick, and less for the healthy. This encouraged appropriate competition for the minority in poor health who actually need the health care system to work for them.

So, if you want an optimal system that in Tyler's words "encourage[s] competition across service quality rather than competition across cost-shifting," you need to devise a system in which the premiums paid the insurer are significantly higher for the sick than the healthy. Strict risk-adjusted premiums have been relatively acceptable in automobile insurance and homeowners insurance, but have been less socially acceptable in health insurance. Every country that has succeeded in making universal health insurance available has either mandated coverage or put the card in each individual's pocket, but also made what they pay a function of their wages or income. One of the reasons we have so many uninsured in the US and are uncomfortable with our current insurance system is that some individuals are underwritten out of the system, and for others, the premium is a head tax, unrelated to income, and often increasing if one's health is poor. Significant subsidies would be needed to bridge the gap between an income related premium that gets everyone insured and the risk-related premium (with incentives to enroll and serve the sick) that Glazer and McGuire identify as optimal to achieve Tyler's goal.

In theory, these subsidies could be put in place by employers to create appropriate incentives for the right kind of competition among insurers (indeed Enthoven suggested this), but such systems would also create stronger incentives than now exist for employers to discriminate in employing or paying workers who are sick or whose families include chronically ill children or spouses. Nor would most employees want their employers to know that much about them or their family.

An alternative is to have government do the pooling and subsidizing. If this is more acceptable, then there may still be a debate about whether to have government contract directly with providers for care (traditional Medicare is the model here) or contract with competing insurers (Medicare Plus Choice and its successor).

Tyler would no doubt argue for competition among plans as the model. As public choice theorists would note and as many opponents of vouchered Medicare have pointed out, there is a strong incentive for government to then skimp on the vouchered amounts. For government paying providers directly, there is an incentive to skimp on payment levels to providers (and we see some evidence of this), but the impact of this incentive is more visible to the public and more subject to political pressure to fix than would a slow, quiet degradation of the value of the government voucher. This would be even truer if the rich and well-connected were served by the same system as the poor and middle class.

So, impossible no, but difficult, and the most acceptable paths are through government, not employer pooling of risk, to pay insurance premiums with appropriate incentives for plans to compete to effectively serve the sick

Posted by: Jack Needleman at Jan 23, 2007 5:25:01 PM

One more quick post: the 3D curve should be drawn so that dz/dx is positive everywhere (the higher your costs the more you pay, i.e. "no moral hazard"), and dz/dy is negative everywhere (you get more subsidies the poorer you are: i.e. a "progressive" structure)

Posted by: mk at Jan 23, 2007 5:27:34 PM

Better means of evaluating doctors and insurance companies come with a better informed more knowledgeable consumer.

Certainly there is a cost to being an informed consumer as well. Every minute I spend learning about the difference between a PPN and an HMO is a minute lost that I will never get to spend with my family or earning money at my job.

Is it really a good use of social resources to ensure that everyone is an health care consumption expert, or would we be better served putting those resources toward a system whereby everyone was able to get what they need when they needed it, and didn't have to think about it the rest of the time?

Posted by: Currier at Jan 23, 2007 5:37:15 PM

"In the short run the plan gives more coverage to the people who need it most,"

How on earth can one make this statement with a straight face, given that the 'benefit' to the uninsured is the ability to deduct health insurance premiums - a benefit which drops to near zero (due to low or zero marginal tax rates) for the group that can't actually afford insurance premiums today?

Posted by: M1EK at Jan 23, 2007 5:54:25 PM

Krugman writes:
No economic analysis I’m aware of says that when Peter chooses a good health plan, he raises Paul’s premiums. And look at the condescension. Will all those who think they have “gold plated” health coverage please raise their hands?

Yeah, that'd be me, right here. What our insurance covers is silly. And, by the way, there are three different levels of coverage: individual, individual plus spouse, individual plus family. The guy - let's call him Peter - with the 5 kids pays the same as the guy with 1 (whom we might call Paul). Peter of course loves this and makes sure that he milks that system for everything it's worth. Kids have a cold? Don't go to Walgreens and pay for OTC drugs, go to the doctor's office and get prescribed Tylenol. He likes to eat, too; so much that he'd prefer getting the blood pressure meds today and the bypass surgery diabetes treatments a few years from now.

Whaddaya suppose this does for Paul, who would prefer to pay for most services out of pocket rather than burden the rest of the employees with every little cost, including the trip to the ER resulting from showing off on his bike? He won't be able to pay out of pocket because the doctor knows his insurance info and know that his insurance plan will pay for everything - including the premium meds plus a nice markup instead of those low-cost generics with the lower markup, which is a nice change of pace from dealing with the stingy plans who want justifications in triplicate, hold payments until the start of next quarter, and manage to lose every fourth submission.

It's funny seeing Krugman simultaneously use and demonstrate the word "condescension" and then do an encore with "sneering".

Russell - I think that the real driver in costs are these everyday decisions rather than the occasional emergency. For the former, informed consumer is the way to go. For the latter, obviously some kind of catastrophic insurance is the way to go. As far as I know, few people know when some rare and deadly bacteria (or a truck) is going to hit them, so adverse selection is not going to be a factor there.

I wonder what is going to happen to all of those other countries' "cheaper" programs when the free ride they get off ours goes away? More than half of all drugs and procedures are first developed or perfected here. That's a fact that nationalization advocates have to "get real" about.

Posted by: Eric H at Jan 24, 2007 12:01:31 AM

It's no secret that our healthcare system is broken, and any fix involving universal care will take years to implement. If the UK and Canada are any indicator, there's no panacea on the horizon, particularly for the 85 million US un- and underinsured. One large choice, tho only a band-aid, is to travel abroad for treatment, particuarly for prohibitively expensive surgeries such as cardio and orthopedics. Our forthcoming consumer guidebook, Patients Beyond Borders: Everybody's Guide to Affordable, World-Class Medical Tourism, helps patients make the decisions whether, when and where to travel for quality care. Millions of folks are suffering right now, and many will die needlessly long before new health plans are implemented, in whatever form they may take.

Posted by: Josef Woodman at Jan 24, 2007 2:16:42 AM

a benefit which drops to near zero (due to low or zero marginal tax rates) for the group that can't actually afford insurance premiums today?

Mike, doesn't much the group with zero marginal tax rates qualify for Medicaid? A surprisingly high amount of the uninsured are relatively healthy young people who don't have jobs that provide it, but not the very poor, who can get Medicaid?

That said, sure, make it a tax credit instead.

Posted by: John Thacker at Jan 24, 2007 1:22:27 PM

I will say, Mike, that this benefit would indeed help people in the middle quintile the most, followed by the second quintile (20-40%) and then the lowest quintile of incomes. It's a net tax increase on the upper quintile, a very small tax cut on the next to upper quintile. Among elsewhere

But, sure, you could make it a credit instead to make it even more progressive. Much of the lowest quintile qualifies for Medicaid, though.

Posted by: John Thacker at Jan 24, 2007 2:01:29 PM

US tax rates based on TAXABLE INCOME:
RATE SINGLE MARRIED
0% < 7,551 <15,101
15% <30,651 <61,301

Number of uninsured by income, US Census:
<$25,000 14.5 million
25-50K 15.0 million
50-75K 7.7 million
75k+ 7.9 million
majority of uninsured in 15% or below bracket

Given standard deductions and variations in state eligibility, still some nonMedicaid eligibles in 0%, lots of nonMedicaid eligible in 15% bracket.

At 15%, tax deduction on a $300/month policy, reduces effective cost from $3600/year to $3060, still pretty steep at the low end of the range.

Posted by: Jack Needleman at Jan 24, 2007 5:29:39 PM

Number of uninsured by income, US Census:
<$25,000 14.5 million
25-50K 15.0 million
50-75K 7.7 million
75k+ 7.9 million

Looks a lot like 45 million (actually 45.1 million) to me. Not "45 million" as a political slogan, but 45 million as a fact.

Posted by: Bernard Yomtov at Jan 24, 2007 9:40:52 PM

45 million as a fact.

Depends on the year. I don't recall which year I grabbed; I was more interested in the distribution. The CPS estimate has been growing in the last several years.

Posted by: Jack Needleman at Jan 25, 2007 9:30:58 PM

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