Category Archives: health care

Is Our Economy Truly Recovering From the Recession?

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In yesterday’s Wall Street Journal, Mortimer Zuckerman, the Chairman of U.S. News and World Report, writes that “A Jobless Recovery is a Phony Recovery”.  He points out that counting the people who want full time work and can’t get it, as well as those who have stopped looking, the real unemployment rate is really 14.3% rather than the officially reported 7.6%.  Enormous fiscal (deficit spending) and monetary (quantitative easing) stimulus has been able to stimulate an average growth rate of only 2% for the past four years since the recession ended in June 2009.  During these last four years the civilian workforce-participation rate has actually declined from 65.7% to 63.5% which has never happened before in an even slowly expanding “recovery” like we have at the present time.
Keynesians and Obama Administration apologists say that we need even more fiscal stimulus (we can worry about deficits and debt later); tax reform won’t help because tax rates are already low; massive new regulations (ObamaCare, Dodd-Frank financial regulations, EPA environmental regulations) are so important that they override negative economic effects; etc.  At some point, the sooner the better, we need to recognize that current policies are not working and are, in fact, retarding the recovery from the recession.
Tax reform is the biggest single change which would help.  Removing deductions and tax preferences, and replacing them with lower tax rates, would give a big boost to investment and entrepreneurship, and thereby be a huge stimulus to the economy.  This includes eliminating the tax exemption for employer provided health insurance.  Combining this reform with repeal of ObamaCare’s Employer Mandate would also lead to getting the cost of healthcare under much better control.  The overall cost of healthcare, 18% of the American economy and growing, is a huge long term burden and must be turned around.
The massive complexity of Dodd-Frank is a huge burden on the financial industry.  Preventing banks from becoming “too big to fail” can be accomplished by having more adequate reserve requirements along with sufficient default and liquidity insurance pools, along with otherwise minimal regulation.
Only more private investment and risk taking can make the economy grow faster and bring down the unemployment rate.  The sooner our national policy makers (and the voters who elect them!) figure this out and act accordingly, the sooner that our economy will truly begin to recover from the Great Recession.

Should the Employer Mandate Be Repealed?

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In last Sunday’s New York Times the columnist Ross Douthat makes an excellent case in “A Hidden Consensus on Health Care”,  that Obamacare’s employer mandate, recently postponed for one year until January 1, 2015, should be repealed altogether.  The reason for delaying its implementation is because of the complexity of the process for the government to gather all the necessary information about a company’s employees and coordinating with IRS tax returns to verify incomes.  This is, of course, a mammoth job.
Furthermore, small and medium sized companies, near the 50 employee cutoff for mandatory coverage, will not have to immediately slow down their growth, in order to avoid the health insurance requirement.  This could help boost the economy in the short turn.
In addition, as Mr. Douthat points out, it is the tax exemption for employer provided health insurance which is the biggest impediment for getting the cost of healthcare under control.  It means that employees are shielded from the true costs involved in receiving care and therefore have little, if any, incentive to hold down the cost of their own care.
If this tax exemption was eliminated, perhaps as part of a broad based tax reform initiative, then employers could still offer an optional health insurance benefit to their employees but it would be taxed as part of their total pay.  This would give employees an interest in holding down the cost of their own insurance.  And they would also have the option to shop around on the private market, perhaps on the new exchanges, for a better deal.
The Employer Mandate is thus altogether a dead weight on our struggling economy.  It’s certainly beneficial to have it postponed for a year.  Let’s go the rest of the way and repeal it altogether!   This would be a significant step towards true healthcare reform!

The Four Fiscal Fantasies

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Jon Cowan and Jim Kessler from the Third Way think tank have just written a new article, “The Four Fiscal Fantasies”, in which they address our country’s current fiscal situation from a point of view which is sympathetic to, but critical of, the left.

  • Fantasy #1:  Taxing the rich solves our problems.
  • Fantasy #2:  We can have it all.
  • Fantasy #3:  Waiting is benign.
  • Fantasy #4:  The politics get better.

These four fantasies are fairly self-explanatory.  The solution they propose for the long term insolvency of Social Security is an at least partial lifting of the FICA cap as well as chain-weighting of the CPI.  These are both good ideas.
Their solution to looming Medicare insolvency is to trim costs in the current program with, for example: bundled payments, medical homes for end-of-life, a permanent fix for the Sustainable Growth Rate (doc fix), reducing duplicative care, increasing provider coordination, etc.  This however is a band aid approach to getting Medicare costs under control.  We need far greater and more fundamental changes in our entire healthcare system, public and private.  Douglas Holtz-Eakin and Avik Roy have a plan to do this which I have discussed in my June 5, 2013 blog post, “Free Market Healthcare in America”.
With respect to discretionary spending in the federal budget, Mr. Cowan and Mr. Kessler propose several specific budget cuts in order to boost spending for other programs for kids, science, research, curing disease, infrastructure, etc.  Savings in one area would be spent on investments in other areas rather than being used for reducing the deficit.
To me this whole program represents a step in the right direction even though it does not come close to all of the changes that will be needed to shrink the deficit down to zero.  If national Democratic leaders would propose this sort of a program, it would force Republican leaders to take it seriously and would therefore break the current logjam in Congress.

Free Market Healthcare in America: How Do We Get There?

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Almost everyone agrees that healthcare in the U.S. is way too expensive but how do we change to a better system?  Douglas Holtz-Eakin and Avik Roy have laid out a roadmap to do this: “The future of free-market healthcare”.  Here is the essence of their plan: 1) start with what we will soon have under Obamacare: subsidized health-insurance exchanges; 2) limit subsidies in the exchanges to incomes up to 300% of the federal poverty level as in Massachusetts and also limit the growth of subsidies to the overall growth rate of the economy; 3) use the exchanges for Medicare reform by raising the eligibility age for Medicare by 3 months each year.  Retirees would then gradually migrate into the defined contribution system of the exchanges; 4) gradually shift Medicaid enrollees into the exchanges.  The exchanges would allow them to move up the income ladder while maintaining their health insurance.
Eventually all low income and retired  Americans would become part of a unified health-insurance system based on the exchanges which would provide subsidies as needed.  I would add one additional feature to this system:  remove the tax exemption from employer provided insurance.  This would, of course, create healthcare cost consciousness amongst employees.  Employers could still offer a health insurance package to their employees but it would become part of their taxable compensation.  They might decide to join an exchange instead for a better deal.
Such a system as outlined above is based on the Swiss free market model.  The Swiss choose their own doctors and have short waiting times for appointments.  The cost of healthcare in Switzerland is about half as much per person as in the U.S. so we would achieve a huge savings.  We have got to make big changes in the way we deliver and pay for healthcare in the U.S. and here is one way to do it!

Colonoscopies Show Why American Health Care is So Expensive

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Yesterday’s New York Times has an excellent article, “The $2.7 Trillion Medical Bill”, which uses a detailed analysis of the cost of colonoscopies to show why American healthcare is so expensive.  In the U.S. an insurance company pays about $3500 – $4000 for a colonoscopy compared with the cost for the procedure in Europe of between $400 – $800.  Also the price can vary enormously, from as little as $665 (in Utah) to as much as $8577 (in New York City).  There are all sorts of reasons for this huge variation in cost, for example, whether or not an anesthesiologist is used as well as a gastroenterologist, and whether the procedure is performed in a surgical center rather than in a doctor’s office.
The basic problem, of course, is that in the U.S. nobody is sufficiently responsible for the bottom line.  The patient isn’t responsible because the bill is paid by the insurance company.  The insurance company negotiates with healthcare providers but the insurance premium is paid by the patient’s employer.  If the insurance company has to pay too much in claims one year, then it just raises insurance premiums for the following year.
The problem is getting so serious that it will soon have to be dealt with in a comprehensive way.  There are essentially two different ways to proceed.  One is to have a single payer system like most of Europe and Canada.  Healthcare would be tightly controlled by the federal government which would set prices and ration care.  The cost of healthcare would be controlled but we’d be giving up a great deal of personal freedom in return.  Basically it would amount to expanding Medicare into a rigidly prescribed national healthcare system.
The alternative is to adopt a new payment system which makes each of us directly responsible for the cost of our own healthcare.  The best way to accomplish this is to remove the tax exemption from employer provided health insurance.  Health insurance could still be provided by an employer but it would be considered a part of total salary and be taxed as such.  Then the employee, as well as any self-employed person, would have a direct personal stake in setting up an efficient health insurance plan to keep the cost of healthcare under control.
Americans put great emphasis on personal freedom and responsibility and I believe that most of us would prefer this latter free market approach to healthcare rather than a single payer system like what most of the rest of the world has!

Is Medicare Out of the Woods?

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The Medicare Trustees have just released their annual report and, according to today’s Wall Street Journal, “Medicare Trustees’ Report Eases Concerns on Funding”.  In 2012 Medicare expenses, most of which are paid out of general government tax revenue, amounted to $574 billion, up 4.6% from 2011.  Although this is a smaller annual increase than usual, it still represents a rate of growth which is much too fast to be sustainable over the long run.  After all, the economy (i.e. GDP) is only growing at a rate of 2% per year and so a rate of 4.6% for Medicare is more than twice as fast as the economy is growing.  Such a rapid rate of growth for Medicare has been going on for many years and simply cannot be continued much longer.
The problem is that Medicare is an open ended entitlement program which pays whatever is needed by its currently 50.7 million retired enrollees, whose number is also increasing rapidly.  The only way that Medicare can possibly survive indefinitely is to be turned into a defined contribution program whereby each enrollee’s annual support is limited to a fixed amount.  Of course, this places responsibility on each enrollee to pay attention to the cost of her/his own medical care.  This is a big change from the present system of government responsibility and so it will take a major change of thinking to make such a big switchover.  But a new system can be phased in over time so that everyone can get used to it.
We really only have two choices.  We can postpone any action along these lines until the cost of the current system is so outlandish that the government is given the authority to severely ration healthcare for senior citizens.  The alternative is to set up, and phase in, a new system so that every enrollee bears responsibility for the cost of her/his own care.  Right now we have the luxury of deciding which of these two systems we want to adopt.  But if we put off the choice much longer, it will be forced upon us by financial necessity.

Is Voucher Really a Dirty Word?

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The current issue (May 25, 2013) of the Economist has an excellent article “Entitlements in America”, which tackles the broad issues of entitlement spending and health care inflation in America.  There are many aspects of this whole problem but let’s focus here on “Medicare, the hardest part of the budget”, as the Economist says and with which I totally agree.  We cannot get government spending under control, i.e. deficits on a steep downward path, until we figure out how to control the cost of Medicare.
The Economist makes some standard recommendations, such as increasing the eligibility age from 65 to 67 (as for Social Security) and raising premiums on the well-to-do (means testing).  These are good ideas but not large enough in scope to make a significant dent on the problem.  Somehow or other we need to convert Medicare from a defined benefit program (with no cap on expenses) to the same kind of limited defined contribution program which everyone else has through private insurance.  But how can we accomplish this within our political process?  Republican House Budget Chair Paul Ryan has taken an enormous amount of heat for proposing to make this switch with a premium support or “voucher” plan.  It is much too easy for Democrats to accuse him of trying to destroy Medicare when he’s really just trying to save it by making it financially sound.
The Economist proposes converting the Federal Employee Health Benefits program into a voucher system as an experiment to see if it saves money.  Right now FEHB offers unlimited benefits with federal employees paying 35% of the cost.  This makes FEHB open ended with no constraint on overall spending, which is exactly the problem with Medicare.  Each federal employee would have an annual health benefit amount and would have to decide on what kind of health insurance benefit to purchase with the fixed amount, supplementing with personal funds if desired.  If a voucher program for federal employees saves money for the federal government, as it undoubtedly would, then we could confidently convert Medicare to a similarly system.
We have to make big changes in our current Medicare program and here is an excellent suggestion for one possible way to do it!

Income Inequality and What to Do About It

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In yesterday’s New York Times Timothy Noah has a column in The Great Divide series “The 1 Percent Are Only Half the Problem” in which he makes the case that there are two different types of inequality which society needs to address.  First, the income gap between the top 1% and the bottom 99% is getting wider and wider.  But there is also a skills gap between the (college) educated class and those whose education ended in high school.
What can and should be done about these two different aspects of inequality in America?  Controlling the excesses on Wall Street in order to avoid future bailouts will help control the wages of the top 1%.  This is already being done with the Dodd-Frank financial reforms and current efforts to require the biggest banks to hold more capital reserves.
But much more could be done.  Unfortunately, the main effect of the Federal Reserve’s low interest rate policy is to drive up the stock market which favors the more affluent.  Broad based tax reform which would lower tax rates by eliminating unjustified tax breaks for the rich would do much more to stimulate faster economic growth and give a big boost to middle class incomes.
The huge and rapidly growing cost of employer provided health care (now averaging about $5000 annually for individual coverage and about $14,000 for family coverage) is having a huge negative impact on middle class wage growth.  The U.S. spends twice as much of GDP, about 18%, on healthcare as any other developed nation.  Reforming employer provided health insurance by removing the tax exemption (and replacing it with lower tax rates) would get each of us personally involved with controlling healthcare costs.
The skills gap is driven by globalization and the advance of technology and is not going to disappear.  The only way to address it is by improving educational outcomes.  Putting more emphasis on early childhood education (ages 0-5) will help as well as making college more accessible and affordable.  Online education and especially Massive, Open, Online Courses (MOOCs) will help in both respects.  Hopefully more and more students and families will come to realize that there are many attractive alternatives to very expensive and elite residential colleges and universities.  It is not necessary to be wealthy or to borrow lots of money to attend college!
Conclusion:  inequality in American society is a large and growing problem.  But there are effective ways for both policy makers and individuals to respond.

Why is American Health Care So Expensive?

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In the May 5, 2013, New York Times columnist Ross Douthat “What Health Insurance Doesn’t Do”, discusses a recent Oregon Medicaid experiment which shows that the Medicaid program improves health outcomes only slightly even though it does help people avoid huge medical bills.  As Mr. Douthat goes on to explain, the Oregon result offers a valuable suggestion for how to make American health care overall much more efficient and less costly.
The problem is that our health insurance system does not function like any other type of insurance.  All other types of insurance such as for house or car protect only against actual disasters like a house burning down and not routine maintenance repairs which affect all of us on a regular basis.  In other words, health insurance could and should be restricted to very expensive treatments such as for cancer, for example.  Routine health problems, which affect everyone over a lifetime, even including end of life care, can and should be paid for with mechanisms such as health savings accounts, which can be rolled over from one year to the next.
A more elaborate discussion of the inefficiency of American health insurance, and how to fix it, is provided by David Goldhill in the NYT on February 17, 2013 “The Health Benefits that Cut Your Pay”, and also in his new book on health care referenced therein.
Clearly the cost of health care is a huge fiscal and economic issue for our country.  Health care entitlements, such as Medicare and Medicaid, are the main drivers of the national debt.  The rapidly growing cost of Medicaid is also a huge problem at the state level because it is crowding out support for other essential major programs such as education and infrastructure improvements.  The cost of private health care paid by employers holds back wage gains and is a major factor in the growing income inequality in American society.
It is time for Americans to demand action on health care costs from our national political leaders.  It is a problem which affects almost all of us and therefore should be amenable to a bipartisan solution in Congress.  We need to get this message out much more strongly!

Is Faster Growth Under Our Control?

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In today’s Wall Street Journal, columnist David Wessel declares that “Faster growth relies on a bump free road”.  Mr. Wessel cites a new forecast from the International Monetary Fund that sees a “three speed recovery” with the U.S. lagging behind emerging markets and developing economies but doing much better than the no-growth Euro zone.  According to Mr. Wessel our own economic growth is so closely tied in with the rest of the world, and especially Europe’s floundering economy, that the best we can do is to avoid “overly strong deficit reduction” and hope that there are no major bumps in the road.
It is pessimistic indeed to assume that there is little if anything we can do to boost economic output.  We can lower both individual and corporate tax rates, offset by eliminating deductions and closing loopholes, in order to stimulate more private investment.  We can help small businesses grow by removing the huge burden of having to provide health insurance to their employees (this can be accomplished by changing the tax treatment of health care insurance).  We can encourage more entrepreneurial activity with targeted (but temporary) tax exemptions. Immigration reform, hopefully now in the works, will boost the productivity of our 11,000,000 illegal immigrants by giving them more economic freedom.
Twenty million U.S. citizens are either unemployed or underemployed.  Our national leaders should consider it to be their moral duty to adopt measures to put more of them back to productive employment.  In addition, as the strongest economy in the world by far, we will boost the entire world economy if we can speed up our own growth.  The benefits of faster growth are so obvious that it should be the first priority of Congress and the President to work together to get this done!