My last three posts: here, here, and here, are concerned with the high cost of American healthcare and how this is so closely tied in with our very large and badly out-of-control national debt. In particular, three giant American companies: Amazon, Berkshire Hathaway, and JP Morgan Chase are forming an independent healthcare company to try to hold down healthcare costs for their combined one million employees in the U.S.
Dr. Elizabeth Rosenthal, an MD and editor-in-chief of Kaiser Health News, points out that this new company may help its own members but end up hurting the rest of us:
Previous efforts along the same line by Safeway and Boeing have held down costs for the companies own employees but are too small scale to have had broader impact.
The new company, much larger in size, may be able to negotiate lower prices from labs and hospitals for its own members. But then these same labs and hospitals will charge more for everyone else.
Moreover, in general, employer based healthcare insurance has lots of problems:
It diminishes incentives to reduce costs by insulating workers from the full price of their benefits.
It discourages changes that could displease even a small number of workers, thereby creating incentives to minimize disruption.
The pervasiveness of employer health insurance makes it more difficult for individuals to buy health insurance on their own, thus discouraging entrepreneurship.
Conclusion. Given the inherent flaws in employer provided health insurance, it is unlikely that more innovation by individual companies, or groups of companies, will lead to an overall solution to the exorbitant cost of American healthcare.
The solution lies in a different direction: ending or at least modifying the ACA’s employer mandate. See here for details. More later!
The Manhattan Institute’s Avik Roy has just released a comprehensive and very impressive new study of the American healthcare system, “Transcending Obamacare: A Patient-Centered Plan for Near-Universal Coverage and Permanent Fiscal Solvency.” By 2025 it will increase insurance coverage by 12.1 million above Affordable Care Act levels. It will at the same time achieve a 30 year deficit reduction of $8 trillion compared to current CBO projections (see chart below). More specifically Mr. Roy’s new Universal Exchange Plan will
Expand coverage well above ACA levels without an individual mandate
Improve the quality of coverage and care for low-income Americans
Make all U.S. healthcare entitlement programs permanently solvent
Reduce the federal deficit without raising taxes
Reduce the cost of health insurance
The five core elements of Mr. Roy’s Plan are:
Exchange Reform. The ACA’s individual mandate is repealed. The Plan restores the primacy of state-based exchanges and insurance regulation. Insurers are encouraged to design policies of high quality tailored to individual need. By lowering the cost of insurance for younger and healthier individuals, the Plan will expand coverage without a mandate.
Employer-sponsored Insurance Reform. The employer mandate is repealed, thereby offering employers a wider range of options for subsidizing employees insurance.
Medicaid Reform. The Plan migrates the Medicaid acute-care population onto the reformed state-based exchanges with 100% federal funding. The Plan returns to the states full financial responsibility for the Medicaid long-termcare population.
Medicare Reform. The Plan gradually raises the Medicare eligibility age by four months each year forever. The end result is to preserve Medicare for current retirees and to maintain future retirees on their exchange-based or employer sponsored health plans.
Other Reforms. The Plan tackles the growing problems of hospital system monopolies and malpractice litigation and also accelerates the pace of medical innovation by reforming the Food and Drug Administration.
These reform proposals are amazingly ambitious and far reaching in scope. How can they possibly be achieved? Stay tuned!
Last Sunday’s Washington Post has an Op Ed column by Jon Kingsdale, “Beyond Healthcare.gov, Obamacare’s Other Challenges” which describes the many challenges confronting ObamaCare besides just the website problems and the millions of individual policies which will be cancelled for not meeting the minimum requirements of the Affordable Care Act. Based on his experience setting up the Massachusetts Health Insurance Exchange from 2006-2010, there will be huge problems in getting enrollment, billing and premium collections working smoothly for such a large government program. For example, an estimated 27% of those who will be eligible for tax credits under the ACA do not have checking accounts. How will their monthly premiums be paid and tracked for these people if they’re late?
Considering all of the problems involved in the implementation of ObamaCare, and the fact that it does not really reform our current very costly healthcare system but rather just extends it to cover more people, it makes much sense to move toward real healthcare reform, which will control costs.
A column in today’s Wall Street Journal by Ramesh Ponnuru and Yuval Levin, “A Conservative Alternative to ObamaCare”, lays out several basic features which should be included in a sensible, market oriented approach to healthcare reform. The principles are:
A flat and universal tax credit for coverage which applies to everyone and not just for employer provided healthcare. The (refundable) credit would be roughly the amount necessary for catastrophic coverage.
Medicaid could be converted into a means-based addition to this tax credit.
Everyone with continuous coverage (which would be provided by the tax credit) would be protected from price spikes or cancellations if they get sick. This provides a strong incentive to buy and retain coverage without the need for a mandate.
A market oriented healthcare system like this is not only preferable to all of the mandates and restrictions of Obamacare, it also improves our current system by both expanding coverage to more people as well as controlling costs by giving health consumers (all of us) a much bigger stake in purchasing healthcare.
The United States spends 18% of GDP on healthcare, twice as much as any other country in the world. Our fiscal stability and future prosperity depend on getting this huge and growing cost under control. The ObamaCare fiasco provides an excellent opportunity to get started on doing this.
In my previous post I laid out the view of the economist, Tyler Cowen, in his new book “Average is Over”, that the powerful trends of globalization, technology, and ever increasing machine intelligence (such as Google’s search engines), will lead to a super elite 10-15% of American’s who will have the ability and self-discipline to master tomorrow’s technology and profit from it. The average middle class worker will be increasingly replaced or downgraded by intelligent machines. Social and economic inequality will continue to grow and this new trend will be very hard to overcome. This is a bleak prospect for the future of America. What can be done to resist this trend and to try to turn it around? Jim Clifton, the CEO of the Gallup Organization, says in “The Coming Jobs War”, that “what everyone in the world wants is a good job” and he has many ideas about how to boost the economy in order to produce more good jobs. According to Mr. Clifton, there is no shortage in this country of creativity, new inventions and innovation. What is lacking are successful business models to commercialize the good ideas which are already out there and create customers for new products. We need entrepreneurship. “Entrepreneurship has a direct impact on supply and demand, but with a distinction. It doesn’t just provide supply, it builds demand.” Next question: how do we boost entrepreneurship? We get government out of the way as much as possible. This means the lowest possible tax rates (offset by eliminating tax loopholes for the wealthy) and fewer burdensome regulations (such as the employer mandate for health insurance). As a society we have to decide which is more important: creating more and better jobs by growing the economy faster or making everyone more equal with higher taxes and more income redistribution. We can’t have it both ways. To reverse or at least slow down the trends which are now shrinking the middle class, the best policy is to go all out for entrepreneurship and investment!
Today’s New York Times reports that “Health Care Costs Climb Moderately, Survey Says”. The average annual insurance premium for a family rose 4% in 2013 compared with a 1.1% overall rate of inflation, according to the Kaiser Family Foundation which conducted the survey. Since 1999 health insurance premiums have increased by almost 300% while consumer prices have increased by 40%. As insurance premiums rise, deductibles are also getting bigger. About 38% of all covered workers now face an annual deductible of $1000 or greater. Dr. Drew Altman, CEO of the Kaiser Foundation, refers to this “quiet revolution” as an attempt by consumers to keep the cost of health insurance from rising even more quickly.
A 4% increase in insurance costs may seem moderate, but at almost four times the rate of inflation, it is really very large. Obama Care is unlikely to have any impact in holding down such a rapid increase and, in fact, is likely to make matters worse because of massive new health care regulations which are coming. The basic problem is that America spends 18% of GDP overall on health care, almost twice as much as any other country.
What can we do about this? One major step would go a long way. We need to remove the tax exemption from employer provided health insurance. Employers could still provide health insurance for their employees, but the cost would be added to an employee’s salary for tax purposes. This can be offset with a lower tax rate, of course. But it would make employees, i.e. all consumers, far more conscious of the cost of healthcare and therefore to have a direct incentive to hold down these costs. For example, Dr. Altman’s “quiet revolution” would pick up steam as employees raise deductibles even higher in order to lower overall costs.
How can we get going in this direction? The Employer Mandate of Obama Care should be repealed, and not just postponed for a year. Ideally, removing the tax exemption for employer provided health insurance would become part of the broad based tax reform which is so badly needed to stimulate the economy.
Our fiscal and economic problems can be addressed with smart leadership. We should insist that our national leaders get going on such badly needed reforms!