Topic: Health Care & Welfare

The Glories of a ‘Single Payer’ Health Care System

I recently attended a conference at Cambridge University, mainly involving Brits, none of whom had a good word to say about the National Health Service. What a change from times past, when so many British people thought it a matter of national pride to boast that “We have the finest health care system in the world.” (When I lived in the UK, I used to ask such people to what world they were referring, ‘cause it sure wasn’t this one.)

Lo and behold, the NHS just released data on “hidden waits,” the time spent waiting for diagnostic tests. As the BBC noted in its coverage:

The figures, for 15 of the most common diagnostic tests including scans, internal examinations and hearing tests, mean that for many patients the wait for diagnosis is as long as the wait for treatment.

If you’re going to get sick with anything serious, be sure to do it in the United States. Even with all the problems facing American medicine and the irrationalities of our financing system, at least you’re likely to find out how sick you are and start treatment before it’s too late.

Medicare Reform: Just Give Seniors the Cash

Matthew Holt at raises a good question about Medicare’s renewed effort to offer medical savings accounts to beneficiaries:

Those taxpayers who can do basic math might wonder why you’d want to to give healthy Medicare beneficiaries cash for health services that they’re not going to use, while taking that cash away from the pot that pays for the sick beneficiaries that do use said services. But we’ve asked that question so many times before and no one on the free market side dare answer it. And I guess you might say, why not give the taxpayers money straight to the “healthys” instead of laundering it through Medicare Advantage plans as we’re doing it now so that they can hand out free gym memberships to seniors and boost their executives’ stock holdings.

But given that risk adjustment is coming to Medicare Advantage, it may be that that gravy train is ending.

The Medicare MSA concept raises some interesting problems. Fortunately, Holt solves them — though I’m not sure he knows it.

A bit of background: The Medicare Advantage program currently pays private health insurers a flat amount for each senior those plans cover. As Holt notes, that encourages the plans to seek out the seniors whose medical bills will be less than that flat amount. Thus some plans “hand out free gym memberships to seniors” as a way to attract the healthy, profitable ones and avoid the unprofitable sick ones. That can end up costing taxpayers more than if those healthy seniors just stayed in traditional Medicare. 

But as Holt says, Medicare is working on adjusting those payments according to each beneficiary’s health risk. Instead of some flat amount per beneficiary, insurers would receive a payment from Medicare that better reflects each individual enrollee’s expected medical expenses. That way, health plans would have less reason to cater to the healthy or to avoid the sick. 

But once Medicare risk-adjusts those payments, why should the insurance companies get that money? As Holt postulates and Mike Tanner and I discuss in Healthy Competition, why not give it to the beneficiary? Confine it to health care uses, if you like. Healthy people would get smaller payments; sicker seniors would get larger ones. That would enable each to purchase health coverage (high-deductible or whatever) and still have some money left over for their out-of-pocket expenses. Seniors would get more control over their health care and coverage; they would make much smarter cost-benefit decisions than they do now; and Congress could limit the burden that Medicare imposes on taxpayers.

Is the point of the program to help insurers? Or providers? Or seniors? To whom do we want insurers and providers to be responsive?

The Spin on Medicaid

The Administration claimed this week that Medicare and Medicaid spending has slowed, but a close look at the overall picture tells a different story. My colleague Michael Cannon has already posted his opinion about Medicare spending.  Here’s the low-down on Medicaid.

The official spin:

Medicaid cost projections are once again declining, reflecting … a slowdown in Federal Medicaid spending growth from over 12 percent per year in fiscal year 2000-2002 to 7.2 percent from 2002-2005, down further to 4.6 percent projected for fiscal year 2006-2007.

And the complete story:

Summary budget tables – updated during the release of the Administration’s Mid-Session Review of the Budget this week – indicate that federal Medicaid and SCHIP (State Children’s Health Insurance Program – also a part of Medicaid) outlays would grow from $129 billion in 2001 to $213 billion by 2008.  That’s a cumulative (geometric) annual average growth rate of 7.7 percent during the Administration’s full tenure.  The nation’s Gross Domestic Product, on the other hand, would grow at a much slower pace – just 5.2 percent per year during the same period.

Much of Medicaid spending growth resulted from the substantial surge in enrollments and benefits per enrollee during the aftermath of the 2001 recession.  Medicaid outlays would be expected to surge during recessions but should abate when growth picks up.  The latter did not occur during the 1991 and 2001 recession episodes.  During the later recession, changes in federal regulations made it easier for states to expand coverage to broader groups and claim federal matching grants against such coverage.  And evidence from micro-data surveys indicates that it was not the poorest groups that received most of the latest increases in Medicaid coverage and benefits.

The reasons for the current slower growth in Medicaid spending are the transfer of the fastest growing prescription drug coverage to Medicare and robust economic growth.  However, according to the Administration’s projections, faster Medicaid spending growth – at 7-plus percent per year – is projected to resume after 2007.

Providing greater power to states to redesign their programs while persisting with a federal financing mechanism of matching grants (rather than block grants with capped growth) promotes states’ incentives to spend more. That will cause…you guessed it…more spending on our middle-class Medicaid entitlement.

Bush Administration’s Reputation for Truth-in-Medicare Sinks. Even. Lower.

I just received a blast email from our friends at the federal Centers for Medicare & Medicaid Services. The subject line reads:

Medicare & Medicaid Spending Projections Are Down Again

Medicare spending is down? HUZZAH! A joyous day for taxpayers, one and all. Wait…what’s that you say? Go beyond the press release and read the actual report the administration released? Okay:

At $2.696 trillion, outlays for 2006 are now estimated to be $12 billion lower than the level estimated in February, accounting for 10 percent of the reduction in the 2006 deficit. The lower estimate of 2006 outlays results primarily from reductions in the projected growth rates for Medicare and Medicaid, particularly estimates of the cost of Medicare’s new prescription drug benefit program… However, in the traditional Medicare fee-for-service programs, projections of increased spending outstrip these savings in the long-term and as a result, total spending in the Medicare and Medicaid programs continues to grow at unsustainable rates.

What? Projections of increased spending outstrip these savings in the long-term? Sometimes I get this wierd feeling that the Bush administration is trying to mislead me.

(My colleague Jagadeesh Gokhale will evaluate the Bush administration’s claims about Medicaid spending in a subsequent post.)

Hey Doc, Does It Hurt When I Do This?

According to

Federal lobbying of the legislative and executive branches totaled $1.2 billion ($1,201,255,222) during the last six months of 2005. This is the first period lobbying expenditures have averaged over $200 million a month. For all of 2005 the total spent was $2,363,102,190.

Lobbying by health care interests led the pack ($183,324,757 spent in the last half of 2005), just as it has for the last 10 or so years.  That might have something to do with the fact that government purchases about half of all health care in the United States and controls the other half indirectly.

The American Medical Association was among the top five organizational spenders ($9,720,000 spent in the last half of 2005) in part because they successfully lobbied to block Medicare payment cuts, which had already been enacted into law and were scheduled to take effect this year.  That would be the third or fourth year in a row that providers have staved off those payment cuts.

Jagadeesh Gokhale and I have a theory.  It is that politicians have no intention of reducing how much Medicare pays providers, but instead use the threat of payment cuts to extract political contributions from doctors and hospitals.

HSA Gumbo

A Lousiana blogger named Dr. Hébert offers a skeptical but open-minded critique of health savings accounts. Hébert is board certified in internal medicine and pediatrics. I addressed many of his criticisms in a recent study on HSAs, but I’ll see if I can tackle his concerns head-on – and perhaps more succinctly.

Here are Hébert’s main concerns, saving the biggest for last.

1. HSAs favor the wealthy. Yeah, that’s pretty much true. But the fault here lies more with the problem that HSAs attempt to correct. The federal tax code has exempted employer-sponsored insurance premiums from payroll and income taxes for over 60 years. The wealthy get the biggest tax breaks from that exemption. (See neat graphics to that effect on pp. 14-15 of my paper.) But money saved or used to purchase health care directly is subject to both types of taxation. That causes people to rely on health “insurance” more than they should. HSAs are an attempt to level the playing field between health savings and out-of-pocket expenditures on the one hand and third-party payment on the other. So extending to HSAs a tax break that already benefits the wealthy naturally will benefit the wealthy more than the poor. Since eliminating those tax breaks entirely doesn’t seem politically feasible, HSAs are the best shot we’ve got for fixing what the tax code has done to the health care sector.

2. Employers won’t pass the savings on to workers. HSAs make it easier for employers to provide less health coverage, because they and/or their workers can contribute money to the worker’s HSA tax-free. But if employers cut back on coverage, how can we be sure that employers will “pass on this savings to their employees by paying higher wages”? In the short term, we can’t be sure; employers could just pocket the savings. (If there are any savings – the rising cost of health insurance could eat up any potential wage increase even if employers cut back on coverage.) It’s in the long run that economists agree that non-cash compensation reduces cash wages. And it’s in the long-run that premium savings will be passed on to workers.

3. HSA rules discriminate against those who want traditional insurance. Okay, I have to agree with Hébert again. And with Jason Furman of NYU. It is inconsistent for HSA supporters to say that people are smart enough to shop around for medical care, but not smart enough to choose their own health insurance. That’s one reason I’ve proposed turning HSAs into “large” HSAs, where you would get a tax break on up to $8,000 in HSA deposits ($16,000 for families) and you could use that money to buy whatever kind of health insurance you prefer.

4. HSAs are not a good deal for those with high expected medical expenses. As I discuss in my paper, HSAs may be unpopular with people whose health insurance currently pays for what are essentially uninsurable expenses. In order for insurance to work, coverage has to be confined to expenses that are unknown. If you try to force insurance to cover known expenses, you drive people out of the market – because they know you’re just trying to extract wealth from them. This is not an argument against subsidies, only an argument against trying to cram subsidies into “insurance.” As I wrote in an exchange with Matthew Holt from

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.

But that hardly means that chronically ill patients won’t like HSA coverage. As the Congressional Research Service notes, HSAs could be popular with many such patients because they offer much more control over one’s medical decisions.

5. HSAs won’t result in higher quality care. Hébert gives two reasons. First, patients not always in a position to shop around, because you can’t comparison shop when you’re on a gurney. Yet as I wrote in my paper:

Most health care spending occurs in circumstances under which the patients can comparison shop. For example, emergency room care accounts for only 3.3 percent of health expenditures. Hospital and nursing home care combined account for 45 percent of personal health care expenditures, yet many hospital expenditures are discretionary. Spending on physicians, prescription drugs, home health care, and other services accounts for 55 percent of personal health care expenditures. Those data suggest that a large share of health care spending does allow time for considering one’s options.

Hébert’s second reason is that medical billing is too complicated for patients to comparison shop. Yet the scenarios he offers are no more complicated than comparing prices for cars or houses or mobile phones with calling plans – and consumers comparison shop for all of those things, sometimes all at once. When they need help finding value, they find an agent (e.g., realtors) to guide them. Which brings me to Hébert’s main critique.

6. HSAs equal less health care, and that’s bad. Hébert’s biggest concern seems to be that HSAs will cause people to cut back on their medical consumption, particularly visits to primary care physicians. The way HSAs are set up right now, many primary care visits are not be covered by insurance, although preventive care may be covered below the deductible. That means that patients may face actual tradeoffs if they want to go to the doctor, and will therefore demand more value. If primary care physicians provide as much value as Hébert believes, he should have nothing to fear from cost-conscious patients. But if it turns out we are wasting money even on primary care – and there’s evidence to suggest that is the case – then maybe primary care physicians will have to focus more on providing value.

Hébert predicts that HSAs will meet the same end as HMOs. I disagree, because HSAs give people more control over their health care decisions, and people are not going to want to give that up. HMOs did exactly the opposite. But Hébert offers a testable hypothesis to which I hope we both shall return in the coming years.

(Hat tip to Trapier Michael, the hardest working man in health policy.)

As the Supply Curve Shifts…

Today’s New York Times runs an oped on the supply of physicians by David C. Goodman, an investigator with the Dartmouth Atlas of Health Care. The Dartmouth Atlas does invaluable work documenting the waste that exists in Medicare and other parts of the U.S. health care sector. Goodman critiques a recommendation by the Association of American Medical Colleges that the United States increase its output of doctors by 30 percent to meet the needs of the growing number of elderly Americans. That critique is excellent as far as it goes, but it seems to miss half the picture.

Goodman argues that increasing the number of physicians will do nothing to improve the quality of health care. He cites the sort of data for which the Dartmouth Atlas is famous:

Many studies have demonstrated that quality of care does not rise along with the number of doctors. Compare Miami and Minneapolis, for example. Miami has 40 percent more doctors per capita than Minneapolis has, and 50 percent more specialists…

The elderly in Miami are subjected to more medical interventions — more echocardiograms and mechanical ventilation in their last six months of life, for example — than elderly patients in Minneapolis are. This also means more hospitalizations, more days in intensive care units, more visits to specialists and more diagnostic tests for the elderly in Miami. It certainly leads to many more doctors employed in Florida. But does this expensive additional medical activity benefit patients?

Apparently not. The elderly in places like Miami do not live longer than those in cities like Minneapolis. According to the Medicare Current Beneficiary Survey, which polls some 12,000 elderly Americans about their health care three times a year, residents of regions with relatively large numbers of doctors are no more satisfied with their care than the elderly who live in places with fewer doctors. And various studies have demonstrated that the essential quality of care in places like Miami — whether you are talking about the treatment of colon cancer, heart attacks or any other specific ailment — is no higher than in cities like Minneapolis.

In other words, doctors in some areas of the country order up a lot of health care that seems to benefit no one but the doctors themselves. All that apparently value-less health care costs workers and taxpayers tens of billions of dollars per year.

But Goodman does not address an equally important question: whether an increase in physician supply could make health care more affordable. In the standard supply and demand model, loosening a constraint on supply shifts the supply curve to the right, which reduces prices. With third-party payers, the process gets pretty attenuated – probably more so when the government is paying than when a private insurer is paying. But that’s not the same thing as saying it breaks down. In fact, it’s hard to believe that increasing the supply of anything by 30 percent over time wouldn’t have an effect on prices.

Goodman might have noted that (1) the persistence of expensive, low-quality care and (2) a relatively unresponsive price mechanism are both enabled by the same same feature of the America’s health care sector: our over-reliance on third-party payment. As Mike Tanner and I noted in Healthy Competition, we even nose out Canada in terms of the share of medical care purchased by third parties.

Fixing that problem could address both cost and quality problems. Miami patients would be less likely to let their doctors order up useless tests if those patients are paying, say, 5 percent or 10 percent of the cost. And price is much more likely to respond to supply shifts if you have 200 million price-sensitive purchasers as opposed to a few hundred third-party payers, not all of which are price-sensitive.

Goodman’s Dartmouth colleague John Wennberg has recommended using medical savings accounts to cut out some of the waste in Medicare. Here’s an idea for getting rid of even more useless medical care: just give Medicare beneficiaries a lump-sum payment, adjusted for their individual health risk, and let them purchase medical care and coverage until it stops providing them value.

That might even change the political dynamics enough that we could eventually put to bed these wasteful political discussions about whether we should allow 30 percent more people to become doctors each year.