Examining My Priors: Health Care Edition

I look at health care and I see the rand study, which appears to be backed up by this recent study, and see health care cost inflation as primarily a function of the 3rd party payment system and a lack of cost sharing. So to me, the ideal health reform would feature creating a universal risk pool and mandate people to buy a naked high deductible health plan with premium and deductible assistance for the poor. I take it as a given that if people have an incentive to economize that they will comparison shop and this will force providers throughout the system to innovate in how they deliver care. However, I think the greatest weakness in this view is that it treats health care as a normal good and presupposes people will be unabashed in getting the best value for their dollar. But people don't always approach health care as a function of healing. A lot of health care involves signaling how much you care. So it's possible in my market driven health care utopia what in fact would happen is that health care would be a proxy for loved ones to demonstrate their love and care for others by spending exorbitant amounts.

PPACA and the Ryan Roadmap

Paul Ryan is set to unveil his plan to reform Medicaid and Medicare. I think his proposals have a snowflakes chance in hell of passage but they might get the debate headed in a positive direction. Ryan's plan basically comprises of two elements: Block granting medicaid and providing those currently under 55 with vouchers to purchase health insurance once they are eligible for Medicare. One of the criticisms that has annoyed me regarding the voucherization of Medicare has been the discussion that by setting the growth of Voucher at CPI+1 that the vouchers over time will cover less care as it will not keep pace with medical inflation. My complaint is not that this isn't necessarily a valid criticism but rather a hypocritical one. Many of the same critics have champion IPAB which is the major driver of cost savings for Medicare in PPACA. The reason they champion IPAB and the reason it would save money if the proponents of IPAB are correct, is that IPAB will be successful in reducing access to care. If that is a virtue of IPAB it cannot be a weakness of vouchers.

Health Policy Rant

One radom point that I would like to make is that I find health policy types never seem to question one of the underpinnings of the current system, namely that it is predicated on 3rd party payments, and its role in hampering innovation and cost control very frustrating. When you walk into your physicians office what should be immediately obvious to you is the substantial overhead costs involved with navigating this system. Even a simple practice will often have a billing department with several staff. This entails significant direct costs in the form of PC&B but indirect costs in the form of higher rent and the ability to see fewer patients as the doctor now also is managing a more complex operation. The conventional liberal response to that is "a-ha, single payer will make this go away". Well, not entirely, you would still have to chase reimbursements but now only from uncle sam. So you could let off some staff but you would you would still have a significant amount of overhead. There would be savings but not as much as one would think. Whereas if you simply paid when you received the service the avearge practice could probably make do with a support staff of one- a scheduler/bookkeeper. That is a small example but one that I think is accessible to most people as it is the extent of our normal interactions with the health care system and it is obviously inefficient.

Question for Progressives

Why is it that with health care, the presumption is that we need an intermediary for routine predictable transactions? Or even non-routine care but that isn't necessarily of the urgent life threatening variety (an MRI, a colonoscopy, etc.)? Why is that a more efficient process than giving people either cash or something akin to an in-kind benefit along the lines of food stamps where people would have a debit card that has restricted purchasing abilities*?

If you insist that there is an intermediary to each transaction, then there will be a considerable amount of overhead costs to facilitate transactions that in other industries don't exist. On its face this is an inefficient set up. Why should someone that practices family medicine need anything more than one staff member who functions effectively as his bookkeeper and scheduler. That additional overhead gets passed on to you in the form of premiums to pay for more staff at the providers office to chase reimbursements and more staff at the insurer to process claims. But additionally, the only possible avenue for cost control is top down as opposed to a bottom up manner that we find in most industries. If I am spending my money directly then I have an incentive to minimize my expenses. For instance, if I have to get a colonoscopy, something that does constitute a significant and expensive procedure, but not urgent, I can research prices and reputation and make a more informed decision. If we make price information available I think initially we will find a wild variance in pricing but that will come down, resulting in significant savings to the average consumer. None of this I think is terribly controversial but it seems that we view health care in such a manner that all rules that apply to other goods and services don't to health care.

* I think the non-paternalistic alternative to providing lower income folks with free or massively subsidized insurance is to just give them cash. The obvious criticism here is that lower income folks having many needs and wants and very little cash will forgo care for other things both wise or unwise. I think there is a middle ground to providing cash and a strictly in kind benefit and that would be something along the lines of a medical debit or credit card that has strict restrictions on purchasing. To a doctor this would be as good as cash but to a grocer it would be worthless thus it would seem to address the fear with someone forgoing necessary care but still retain the efficiency of reducing the parties to a routine transaction.

Nevermind, Repeal HCR

Ezra Klein has a post begging us to remember the story of Deamonte Driver when we think of the plight of the uninsured. For those unfamiliar with Deamonte's tragic story, Deamonte was a 12 year old who passed away several years ago as an abcess in his tooth which then spread to his brain, multiple operations and $250,000 later Deamonte died from what could have been solved by a routine tooth extraction. The only problem with Ezra's plea is that Deamonte was covered under medicaid and area dentists that accept medicaid are few and far between. Medicaid is crap and health care reform is expanding it. What we should be doing enabling people to buy catastrophic coverage to protect them from a medical bankruptcy, and providing cash support to cover the deductible for those who are lower income. What if Deamonte's mother could have walked into a dentist's office and said that she was prepared to pay the $100 for a tooth extraction there on the spot, the dentist wouldn't have to wait six months to get reimbursed by medicaid? My guess is that Deamonte would be alive. Ezra Klein has been a tireless advocate for the uninsured and has brought a lot of light to the health care debate, but this is a post that he will forever regret as it is beyond stupid.

I don't think we should actually repeal HCR, but if we are creating insurance exchanges and then also subsidizing the purchase of insurance, why have medicaid? Or at least why not reform medicaid away from this centrally planned price setting model to one that is cash based. Give people a health debit card. Something along the lines of Marty Feldstein's proposal.

Update: I just reread Ezra's post and it still totally blows my mind. He owes his readers an apology. This is the type of error that gets right wingers nominated for stupidest person alive by Brad DeLong.

Bipartisan Health Care

With the individual mandate possibly in doubt (depending on Anthony Kennedy's mood at the moment) some are speculating that PPACA will need to be heavily modified. Unfortunately, I don't think that the health care bill will be significantly changed anytime soon. I think Republicans would rather have a bad and unpopular policy to campaign against in 2012 than actually do something to fix it. This is foolish because while I do think PPACA is bad policy it is not beyond repair. Additionally, irrrespective of whether or not it is improved upon, I don't think it will be unpopular for long (people love spending other people's money). Anyhow, in the event that Republicans decided that they would actually like to make some good policy, Donald Taylor has proposed something that they might find somewhat congenial. The meat of his policy would be:

1. for medicare to offer catastrophic coverage to every individual and family (Taylor says caps of $10k and $15k respectively, I wonder if he is referring to deductibles)

2. to offer premium support (who qualifies is undefined) for insurance to cover the gap

3. Employer tax exclusion would be eliminated to fund the above.

The first sticking point I see is I doubt republicans would be keen on having medicare for everyone even if it were a catastrophic program. I could live with this. The second sticking point that I envision is the relatively high deductible before medicare kicks in. I don't actually have a problem with it, this would limit the government's exposure in the outyears significantly, however, it sort of shocks the eyes when you see it. There is something of a lock-in effect that makes even a deductible as low as $2500 shocking to people. People have been conditioned to think of first dollar coverage as being free as it is provided by their employer (even though it as at the expense of wages).

Mr. Taylor suggests premium support for "gap insurance". I am of two minds on this. If you go back to the Rand study it appears that people actually manage to be competent health care consumers, with the exception of lower income folks (specifically those with chronic conditions). They are more likely to forgo care if they don't have first dollar coverage (even if their income is supplemented to offset the difference). In the Rand experiment, my understanding is that people were randomly assigned to different health plans but they were provided with side payments to equalize their economic circumstances. So for instance, let's say I had a gold plated plan that normally cost $10k with no copay and no coninsurance and no deductible and was assigned to a plan that cost $2.5k and had a $5k deductible. In the Rand study I would have been provided the cash to cover the deductible and possibly more. The central finding was that people spent considerably less the more coinsurance was involved while having a negligible impact on health outcomes. As I said, the real caveat was for poor folks with chronic conditions such as hypertension. This would indicate that providing first dollar coverage to the very poor would ultimately benefit health outcomes and should be considered preferable to a simple cash benefit. My question is would first dollar coverage also be preferable to something along a health savings account or MediSave (a la Signapore) where unlike cash your only option is to spend the money on health care? If the answer is yes, then so be it. If the answer is no then I think the some sort of either tax incentivized savings regimen (like an HSA) or more preferably a MediSave account (forced savings accounts used in Signapore) would be more preferable as a straight cash transaction involves less overhead and forces the consumer to to be price conscious and evaluate the tradeoffs involved in a given treatment.

Health Care Passes

Republicans lost, I would argue so did our nation's finances. Things Republicans should focus on in the next congress on improving health care and making it affordable long term:
1. Change the definition of the minimum benefit to HDHP
2. As part of tax reform cap the employer exclusion
3. Enable the purchase of insurance across state lines

More Insurance Equals Better Insurance

This is the underlying premise of health care reform, that we need to further insulate consumers from costs of their health care. I come from the opposite premise; we need to insure against catastrophe and for the most of the population leave it to them to cover predictable expenses. In every other avenue of life, we do not buy a financial product whose sole purpose is to add parties to a predictable transaction. Why should health care be different?

Who Needs the Public Option

I think Obamacare is an Obamanation but it amuses me that progressives find the absence of a public option to be so disheartening. The legislation will force insurers to issue a policy to all that want one, forbids any price differentiation based on risk, guarantees renewal, defines minimum benefit levels, and now effectively establishes price caps. Insurance companies will effectively be public utilities. The only distinguishing factor between insurance companies and the public option would be the statutory authority to use medicare reimbursement rates.

CBO Scuttebutt

One of the things that will be interesting to see with the President's new health care proposal (this is supposed to be a compromise between the Senate and House bills) is how the CBO treats it. At first blush it appears that the revenue and subsidy changes are modest and should only inflate the bill's 10 year budget number slightly. However, in the president's proposal the government would obtain the authority to reject rate hikes by insurers. This coupled with all of the other changes in the bill would in effect reduce insurers to public utilities. It is conceivable that the CBO would decide that premiums paid should thus be recorded on budget thus massively inflating the budget number.

SOTU Thoughts

President Obama will give the SOTU in five minutes. It will be very interesting to see what remarks he has on health care reform. I can see him going one of three ways: 1. Trying to sell reform and implore the House to finish up the job; 2. Also suggest a path to a scaled down health care bill; 3. Not mentioning it. My guess is he will go with option 1. There is some discussion bubbling up that the House would be willing to vote on the Senate bill if the Senate took up amendments to the Senate version in Reconciliation. The other big expectations are that Obama will publicly push Congress to repeal "Don't Ask, Don't Tell". Obama is also expected to announce a spending freeze in discretionary spending. That is small beer. The other issue to watch out for is financial reform.

My Modest, Scaled Down Bipartisan Healthcare Plan

Step 1- Revenues and moving away from the employer-based system-

I propose a full phase out of the employer exclusion for those with incomes above $125 k for an individual/ $250 k for a household. This would only yield a modest amount of revenue assuming a static model. There aren't all that many households that would fall into bracket, however, those that do tend to be upper middle management. I think once hr directors across the country see their tax liability go up anywhere from $2-5k that they may rethink the virtues of having their company "provide" their healthcare. This would not cause every company to cash out their fringe benefits and only pay cash wages but it would significantly shift things in this direction.

Now, obviously, getting rid of the employer exclusion would transform compensation norms away from non-taxable benefits to taxable wages much more quickly, but this is probably not politically possible. One could argue that touching the employer exclusion is basically impossible as evidenced by the fact that an incredibly weak excise tax (this was basically a roundabout way of gradually eroding the employer exclusion-really gradually, like decades) sent labor into a tizzy and is arguably the proximate cause for the failure of current health reform bill (that and the fact that house democrats are apparently stupid and timid). I think what distinguishes this proposal is that labor's ox is not getting gored by and large. Most union members do make good salaries but not on this order. Rather, it is a soak the rich proposal which usually is politically palatable. The strength of the proposal is not that the rich will be successfully soaked but in attempting to avoid being soaked explicitly will drastically change the way companies pay their employees. Far fetched, I don't think so.

Step 2- Dump people into the individual market and let them buy insurance across state lines

I know, the individual insurance market is horrible, yadda yadda yadda. One of the basic problems with the individual market is that many states suffer from minimum benefit creep. If you live in New York or some other states where there are very generous mandated benefits chances are your choice is between buying a policy that is exorbitantly expensive and going uninsured. Given that you need food and shelter, the choice most people make is to go uninsured. In choosing between protecting folks from catastrophe on one side and providing insurance that has a no-copay for acupuncture treatments on the other side, I think the providing protection against catastrophic bit is more important.

Why propose buying across state lines as opposed to a national exchange? National exchanges, while a great idea in theory, are likely to be a cess pool for rent seeking. The notion of a basic catastrophic plan being offered unmolested by gentle nudges from the hill (in response to contributions from the AMA) is simply inconceivable. One could counter that without national exchanges, buying across state lines will promulgate a regulatory race to the bottom. Yes, this is a feature of my plan, not a bug (within reason, addressed later in the blog). In the end, my underlying assumption is that we insure ourselves in a perverse manner, and are incentivized to do so by tax incentives. I don't think it is necessary to add third and fourth parties to a simple transaction covering a predictable expense. Thus, my optimal insurance plan would be a pure high deductible plan where you pay cash directly to the provider until you hit the deductible where the insurer would take over (as the deductible would be around $2,500 for an individual the likelihood that you would hit it in a given year is very low). By going the federalism route such a insurance product is more likely to survive.

Step 3. Mandate a couple of insurance reforms- no rescission, guaranteed issue

The danger of buying across state lines and the attendant race to the bottom is the prospect of incentivizing rescission. Ban it, problem solved. This would make premiums more expensive, however...

Step 4. A Federal Catastrophic Reinsurance Plan

People with pre-existing conditions are basically uninsurable. I liked John Kerry's proposal during the 2004 campaign for catastrophic reinsurance. The basic contours of his plan was that after a certain threshold (I think it was $75k) the government would pay half the cost. I wouldn't touch community rating however as it does away with the one thing insurers do well, price risk(never mind that whole AIG thing, nothing to see here). If there was a federal catastrophic reinsurance plan insurers wouldn't have the incentive, or nearly as much of one to screen for pre-existing conditions, but they would have an incentive to price according to certain unhealthy behaviors- like smoking.

Step 5. Use revenues from step 1 to provide a refundable tax credit to those under 200% of the poverty line in amount sufficient to cover the premium and 75% of the deductible. Phase out the deductible contribution and premium coverage by 350% above the poverty level.

Step 6. An individual mandate. Again, if people want to blow their nonrefundable tax credit on crack that is fine with me, but they should have to pay a penalty. A HDHP by itself in VA (my lovely home state) is about $1500 per annum. A penalty of $500 would probably incent most to go ahead an buy the insurance.

Sidebar- Federalize medicaid and get rid of the State and Local tax deduction.

This plan would be considerably less expensive than the currently proposed one, would do more to reform the system, and in the long run would have greater likelihood of containing costs. It would probably be disruptive though.

Health Care Reform is Dead

Labor is throwing a fuss about the excise tax and has now declared opposition to the Senate bill.

I think this effectively kills the reform effort. Even with Brown's election the house could vote on the Senate bill that has passed exactly as it was written and pass it into law (the ping-pong route). This would obviate the need for an additional senate cloture vote that would be necessary if the bill went to conference, which became increasingly important as of yesterday when the Democrats lost their 60th vote. However, now that labor is opposing the senate bill this makes ping pong route unlikely.

The Senate could try to craft new legislation but it no longer has the 60 votes unless it is able to turn a republican or two. Obviously this raises Olympia Snowe's importance. The important question is will Olympia Snowe be willing to ditch the excise tax and embrace a revenue measure that is likely to pass in the house (such as a surcharge on top-earners). I view this as unlikely.

I still think some bill will be passed that is called health care reform but it will be substantially less ambitious.

Pricing Transparency in Health Care

Matt Yglesias, normally super intelligent blogger, has made a breathtakingly stupid argument against the potential efficacy of pricing transparency in health care:

"I went to the Maine version of this idea and decided to pretend that I was living at my dad’s summer house in North Brooklin, ME and was considering my hospital options. It turns out that the closest place to get a knee MRI costs $1,550 and is a 40 minute drive to Ellsworth. There are two slightly cheaper options in Bangor—$1,159 or $1,160—but that’s more like a 75-80 minute drive. So the competition in this market is not very fierce. Bangor is the second-largest city in the state; it’s not convenient to get there from Brooklin, and even there you only have two options. Possibly not the best test case for these ideas."

An additional hour of driving would save the hypothetical patient $350. How many jobs pay you $350 per hour? Unless you work for Goldman Sachs, work for KPMG fudging Goldman Sachs books, or are a lawyer helping Goldman Sachs fudge their financial statements, very few. The problem is twofold: 1) Most people lack the information to comparison shop (health care reform should remedy this), and 2) people largely lack the incentive to use that information to economize (health care reform will not remedy this, rather it will exacerbate this trend). Presently people do not have the incentive to economize as they are not directly paying for the procedure. Rather, the insurer is paying for the procedure and then passing on the additional cost in the form of higher premiums. If people were exposed to the additional cost then they would have an incentive to economize it would drive prices down and also premiums.

AARP and AMA Endorse Health Care Plan

What meaning can one discern from these endorsements? This certainly indicates a greater likelihood for passage of health care reform. However, it is also indicative of what two important groups (Seniors and Doctors) perceive of the likely success of cost controls.

AARP

AARP's endorsement indicates that it thinks one of two things will occur: (1) the proposed medicare savings (which represent the majority of the cost savings in the health care reform bill) will not affect seniors care; or, (2) the congress will never pursue the cost savings proposed (a la the annual kabuki with provider reimbursement rate cuts). This may be cynical, but I think AARP envisions the latter not the former transpiring.

AMA

Health Care reform would represent a boon to doctors in that it would expand the market for their services. There would be 21 million new, paying customers which would increase their overall volume and also the prices they can command. In theory, this would be mitigated to some degree by Medicare reimbursement cuts and reforms; but I suspect, the AMA also recognizes that these aspects of the health care reform are unlikely to materialize.

My Prediction on Health Care

I think the bill will ultimately die. I think once it gets to the floor the amendment process will yield more extensive coverage benefits, reduced medicare cuts, and weakened pay-fors causing the bill to collapse in on itself.

Other People's Money

The graph above is very telling. Over the last thirty years out of pocket spending has fallen precipitously. In this same period health care expenditures have risen tremendously. The reason I focus on out of pocket spending is that it's absence is illustrative of two major definciencies in the health care system:

1. Administrative Inefficiency (at an absurd level): Adding third and fourth parties to a transaction typically raises the cost of said transaction

2. Perverse Incentives: When you are spending other people's money you are more prone to waste. In the health care context this is the equivalent of ordering expensive tests with limited value, brand name drugs were generic drugs are adequate, etc.

Samwick on Health Reform

Andrew Samwick has a great post on health care. He discusses an issue that is what I think is a central issue in our high cost of health care but is rarely explored: why does health care operate in a manner so distinct from other markets.

Believing Your Own Spin, pt. 2

Ezra Klein again:

"Atlanta: If it's so easy to save $500-600 BILLION on medicare (doesn't Obama say: we can cut payments for medicare by that much?) - then why don't they just pass that bill?

Are they saying there is that much waste in the program? Why are they holding that money hostage? If it's the lowest hanging fruit (they say it is, it must be true) - just pass whatever needs to pass to save that money. Would anyone vote against that bill? Really?

Ezra Klein: Oh yeah. Saving that money isn't the hardest thing in the world, but nor is it the easiest. A lot of politicians are willing to do it if they also get health-care reform out of the deal. But they're not willing to do it if it's not part of a trade.

I've said this again and again, if the Republican Party included real deficit hawks, they could make an incredible bargain here. They could rip up the employer tax deduction and create a powerhouse MedPAC board and much, much more. The fact that they're just crossing their arms and shouting "no" suggests they're not particularly worried about spending, after all."

He is right that the Republicans have largely limited their participation in the reform effort to say no, however, the one substantive idea that Republicans have offered is to rip up the employer tax deduction or cap it. This was a center piece of the McCain health care plan, and consequently became the target of a very effective (and opportunistic and shameless) attack ad by the Obama campaign. Obama and the unions have taken the employer tax deduction off the table, not the Republicans. This is unfortunate because it manages to achieve two very important things at once: 1. raise revenue; 2. Control costs.

Believing Your Own Spin

Here is Ezra Klein, a blogger I regularly follow, like, and disagree with:

"Portland: So, have YOU ever actually had bulls testicles, a la Padma? If not, would you??

Second question - why this 2013 start date for reform? That's a llllong time from now.... And do you think if this passes and the Republicans regain control of Congress before 2013 they can just undo it before it even starts?

Ezra Klein: I have not, but certainly would try them.

As for 2013, there are two answers. One is that it can't be implemented till then for technical reasons. I think there's more to this than people are giving it credit for. The second is that it makes hc reform look cheaper in the 10-year window, which helps for budgeting."

Ezra gives 2 of 3 reasons why 2013 is when a lot of the health care bill is slated to ramp up:

1. Implementation is actually difficult.

2. Postponing implementation is a budget gimmick used to keep the cost artificially low (if you only show expenditures in five years out of a ten year budget window the program will appear cheaper than it really is).

And what Ezra omitted.

3. 2013 is after 2012, an election year. In the event that the reform is unpopular people will not be able to express the dissatisfaction for several more years.

That is sort of an obvious one. When you omit something like that you might as well be on payroll.