Topic: Health Care

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

By
Michael F. Cannon

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.)

Topics: 
General, Health Care, Tax and Budget Policy

Hey Doc, Does It Hurt When I Do This?

By
Michael F. Cannon

According to PoliticalMoneyLine.com:

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.

Topics: 
General, Government and Politics, Health Care, Tax and Budget Policy

HSA Gumbo

By
Michael F. Cannon

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 TheHealthCareBlog.com:

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.)

Topics: 
Cato Publications, General, Health Care

As the Supply Curve Shifts…

By
Michael F. Cannon

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.

Topics: 
Cato Publications, General, Health Care, Regulatory Studies

Crocko

By
Michael F. Cannon

Filmmaker Michael Moore is not doing much to inspire confidence in Sicko, his upcoming film on the U.S. health care sector. According to Variety.com, Moore wrote the following in an email to supporters:

If people ask, we tell them Sicko is a comedy about the 45 million people with no health care in the richest country on Earth.

One can only assume Moore is talking about “the” 45 million Americans who lack health insurance. Never mind that a lot of them will not be among those who lack health insurance tomorrow. Never mind either that government eggheads believe “that the estimate is inflated due to poor reporting of Medicaid coverage and perhaps other coverage types as well.”

No, what’s really interesting is that Moore says the uninsured receive no health care. He might be surprised to know that people have actually researched this topic. In 2003, the journal Health Affairs published an article titled, “How Much Medical Care Do The Uninsured Use, And Who Pays For It?” Turns out the uninsured received $99 billion of health care in 2001. The uninsured probably receive even more health care today.

Now, you might think $99 billion is not enough. You might even think $99 billion is too much. But if you think $99 billion equals $0, you might be Michael Moore.

I’m actually looking forward to agreeing with Sicko about how the U.S. health care sector is bloated and inefficient, and how health care providers routinely rip off taxpayers. But I can’t help this feeling that Moore is going to recommend that we turn that mess over to a sector of the economy that is even larger, even less efficient, and an even bigger rip off.

I’m hoping for a surprise ending.

Topics: 
General, Health Care

Competitive Federalism Can Reform Health Insurance, Med Mal

By
Michael F. Cannon

In a previous post, I suggested that my brother and his family could save thousands on their health insurance if they moved in with his former college roommate’s family in Pennsylvania, rather than settle and buy coverage in New Jersey.

I thought that former roommate’s wife (Kristin, another college friend) would shoot me virtual daggers. Instead, she wrote:

Wow — guess we’re pretty lucky! Although, we can’t seem to keep our doctors here in PA due to high malpractice insurance costs. So maybe the best deal for everyone would be to buy their insurance in PA, then drive to NJ for their doctor’s appointments.

That’s one way to get around unwanted costs imposed by a state’s medical malpractice laws. In our book Healthy Competition, Mike Tanner and I suggest another: Let patients, doctors, hospitals, and insurers agree up front on the level of malpractice protection that patients receive.

 

You like caps on non-economic damages? Sign yourself right up. You want more malpractice protection than that? It might cost you more, but the choice is yours. The contracts that providers are willing to write could even tell patients something about the quality of care.

Patients can already choose a different level of malpractice protection by traveling out-of-state or out-of-country for treatment. Why not let them do so without leaving home?

Topics: 
Cato Publications, General, Health Care, Law and Civil Liberties, Regulatory Studies

Medicare Part D: Who Is the Main Constituency?

By
Michael F. Cannon

Watson Wyatt Worldwide has just released a survey showing – again – that Medicare Part D’s employer subsidies and the availability of the new stand-alone drug plans are bailing out employers who can no longer deliver on their promises to retirees:

Despite widespread use of the Medicare federal subsidy, a vast majority of employers are planning to curtail their retiree medical plans for current and future retirees in the next five years…

Fourteen percent of employers plan to eliminate the benefit entirely for future post-65 retirees and 6 percent plan to eliminate it for their current post-65 retirees…

The lesson from the Pension Benefits Guarantee Corporation and other corporate bailouts could not be more clear: if government lets corporations escape the costs of making promises they can’t keep, we’ll get more corporations making promises they can’t keep.

Topics: 
Cato Publications, General, Health Care, Regulatory Studies

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