Topic: Cato Publications

Holt & HSAs: Perhaps Fruitful after All

Matthew Holt writes:

The argument I want to have is a theoretical one about what would happen if we had essentially a completely personalized account-based system, as he advocates in his Large HSA proposal.

Holt raises important questions about what would happen under a system of large HSAs, where workers would get a large but limited tax break for cash that they (and/or their employer) deposit in an HSA – tax-free cash that workers could use for health savings, spending, or insurance as they wish.

Holt’s first concern is that “a significant number of people would take the money and buy no or minimal insurance coverage.” That some would choose to drop health insurance is certainly a possibility. I have two responses. First, that is already an option. People can and do choose to “go bare” and use their money for savings or other spending. The large HSA approach could marginally increase the number of people who do that, but only if the newly “bare” actually put money aside for future medical expenses. (Actually, large HSAs could even encourage today’s non-saving uninsured to start saving for their health expenses.) That brings me to my second response. If large HSAs do increase the number of people who “go bare,” the only people they would add to the ranks of the uninsured would be savers. As those “health savers” build up large balances in their large HSAs, it will occur to them, “Gee, one serious illness could wipe out all the money I’ve got stashed in my HSA.” How do people typically protect their assets from such unforseen losses? Insurance. So there’s a built-in incentive for health savers to purchase insurance.

Holt’s second concern goes like this: Were we to allow people to take all of their health benefits in the form of a cash contribution into a large HSA, and let them choose how to allocate those funds (among savings, spending, and insurance), that would begin a process known as “risk segmentation.” As I describe in my paper, some people would “go bare,” many would purchase less comprehensive health coverage, and many would migrate to the individual insurance market, where their premiums (typically) would be based on their individual health risk. What concerns Holt is that sicker people would have to pay more for health insurance, to the point where many sick people could not afford it.

My response is not that sick people should not be subsidized.  (I would prefer that they not be subsidized by government, but let’s assume that all options are open.) It is that sick people should not be subsidized through the vehicle of “insurance.” Attempting to deliver such subsidies through “insurance” destroys much of the good that insurance markets accomplish. Insurance premiums cease to deliver price signals about the costs of bad behaviors (e.g., smoking, obesity, waiting until you’re sick before you buy insurance). Many consumers drop insurance rather than pay the higher-than-necessary premiums, which increases the number of uninsured and tempts government to force people to buy insurance. Most importantly, when patients are spending someone else’s money, we lose a very important ally in the fight to curb wasteful medical expenditures: the patient. Instead of nagging providers about delivering value for the dollar, patients – especially the high-cost ones – line up with providers on the side of more spending. 

My preference is to let insurance markets do all they can do to improve efficiency, particularly by encouraging patients to pay directly more often. Some people will still require assistance, though with a more efficient health care sector their numbers should be smaller. We should subsidize those who remain directly, with cash.

I’m not sure how much of this Holt will find persuasive. Given that we agree that providers are riding the gravy train, I would think that having millions of patients nagging providers about value would hold some appeal.

He and I agree on something else. HSA supporters too often ignore these issues.

New at Cato Unbound: Robin Hanson on Creativity and Smart Machines

In his reply to Rise of the Creative Class author Richard Florida’s lead essay, George Mason economist Robin Hanson argues that creativity matters less for economic growth and the future of work than Florida thinks. According to Hanson, Florida’s emphasis on creativity distracts us from the prospect of a truly revolutionary change just over the horizon: rapidly exponential growth driven by smart machines. “An economy with intelligent machines could grow very rapidly indeed,” Hanson argues, “and induce rapidly falling human wages.” Will we be prepared if we’re busy making the Creative Class comfortable?

Response to Holt

My back and forth with Matthew Holt on HSAs continues…

In my previous post, I wrote that Holt’s critique of my paper made it appear that he hadn’t read the paper very closely. As I understand his response, he is “not very interested” in doing so. He is already convinced that we need “compulsory social insurance” with “incentives for providers that induce them to provide cost-efficient care.” Fair enough.

Or maybe not. Holt continues to misrepresent my views and what that paper says. He variously accuses me of believing that his owning an HSA invalidates his criticisms of HSAs; believing that health insurance is unnecessary; and having no interest in (or proposals for) reducing the burden of expensive flat-of-the-curve medicine. These and other errors could have been avoided by carefully reading my paper.

Since this exchange seems to be bearing little fruit, I will not take it much beyond the following brief summary of my actual views on these issues.

There are some medical expenditures that should not be covered by insurance. Beyond a certain point, problems of moral hazard, fraud, low-quality care, medical errors, and loss of control over one’s medical decisions tend to overwhelm the benefits of additional coverage. (This occurs whether the excess coverage comes through the private sector or the public sector, and even if the state limits supply.) Consumers do a better job than government of establishing coverage up to that point and then stopping. That argues for letting consumers control all the dollars involved, which is at the heart of my large HSAs proposal.

In other words, if you want to subsidize uninsurable medical expenses, you don’t want to do it through insurance. You would do less damage by giving them cash.

Unnecessary Restrictions Are Holding HSAs Back

Federal law requires consumers to have a “qualified high-deductible health plan” before they can open a tax-free health savings account (HSA).  Today, Sarah Rubenstein of the Wall Street Journal reports that those rules make HSA-compatible coverage more expensive than necessary. 

In a recent paper, I argued that Congress actually requires HSA holders to have a “high-but-not-too-high-deductible health plan,” and that Congress should let consumers choose their own health insurance.

New at Cato Unbound: Richard Florida on the Future of Work

Today, in the hot-off-the-WordPress new edition of Cato Unbound, Richard Florida writes about “The Future of the American Workforce in the Global Creative Economy.”

Bestselling author of Rise of the Creative Class, Florida argues that the old industrial era has given way to a new creative era. Science and technology, art and design, and culture and entertainment have superceded natural resources and industrial infrastructure as the key to economic success. Talent is now the key factor of production and winners in global economic competition will be those who can best deploy and attract it. However, the creative economy is a source of increasing inequality both within and between nations. Florida argues that the key to bridging the gap between the creative and service sectors is to harness the creativity of service sector workers to make their jobs both higher-paying and more satisfying.

Florida’s essay is just the beginning of what promises to be an eye-opening conversation about “The Future of Work.” Big-thinkers Robin Hanson, Ed Leamer, and Frank Levy will reply in the days to come. As always, bloggers are encouraged to join the fray and respond to Cato Unbound essayists on their home turf; we’ll excerpt and reprint some of the best of the blogosphere.

Next Week at Cato Unbound: The Future of Work

Join us next week for the June issue of Cato Unbound devoted to glimpsing the future of work in America.

Richard Florida, author of the bestselling Rise of the Creative Class, will lead off with an essay this coming Monday. Replying to Florida over the following week and a half will be: George Mason economist and futurist Robin Hanson, an expert on robot economics [pdf]; UCLA economist Edward Leamer, author of a much-circulated review [pdf] of Thomas Friedman’s The World Is Flat; and MIT economist Frank Levy, co-author of The New Division of Labor: How Computers are Creating the New Job Market.

Here’s what they’ll be talking about:

The economists tell us that technology is a substitute for some forms of human capital and a complement to others. As the pace of technological advance continues to quicken, the “information age” evolves into something new, and the world economy becomes ever more integrated, the most economically valued set of human skills and capabilities continues to shift rapidly. Tens of millions of Americans used to make, and many still do make, a good living in low- and medium-skilled assembly line jobs. However, many of these jobs can now be done at less expense by machines, or by lower-paid workers in poorer countries like China and India. At the same time, the return on investment in education continues to rise, widening the gap in pay between workers with college degrees and workers without them. What do these trends mean for the future of work in America? Are there any jobs safe from mechanization and outsourcing? If part of rising inequality a function of the match between technology and human capital, what can be done to ensure that more people develop the right kind of capital? In a changing global economy, what is America’s comparative advantage? If you had a child tomorrow, and wanted her to get ahead, what would you want her to pick as her college major eighteen years from now?

Join us next week for a provocative look at the future of work in our high-tech, globalized world.