Tag Archives: health care

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!

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!

Whither the American Economy? II

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In today’s Wall Street Journal the columnist Holman Jenkins, with “The Reinhart and Rogoff Distraction”, writes that “Washington has signally failed to enact confidence-building and growth-inducing reforms that would make its fiscal and monetary stimulus seem less reckless and more like part of a coherent therapy.  The real problem is the incentive of voters and their representatives to stonewall any serious adjustment to the status quo….Hardly has the time been riper for another reform spasm like the Carter-era deregulation efforts, Reagan’s tax overhaul, … The ill-timed Obama campaign to magnify the perversities of our health-care system epitomizes a failure of political leadership to do its part to make the global monetary Hail Mary come off.”
The Republican House can slam on the brakes to try to slow down excessive federal spending but there is not much else it can do by itself.  The Democratic Senate is showing that it can address important but less central issues like Gun Control and Immigration Reform.  But only the President can provide game changing leadership on our fundamental economic and fiscal problems.  His political base of liberals and minorities does not want either spending cuts or reduction in tax rates.  So he proposes spending increases, small adjustments to entitlements, and tax increases on the wealthy.  This amounts to a political posture in order to appear to be addressing important issues without really engaging on them.
What has Obama accomplished?  He has shown that a liberal can be elected President  but can’t govern effectively from the left.  What is the likely outcome?  A stagnant economy with a slowly dropping unemployment rate from now until 2016 when we’ll have our next chance to vote for a reform agenda.  Eventually our rapidly growing national debt will lead to a new fiscal crisis, much worse than the Great Recession which we’ve just been through.  However it probably won’t happen until sometime after 2016.  So Obama is temporarily off the hook, so to speak, but he’ll still catch much blame later on.
Oh well, what is life without challenges!

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!

How Can American Health Care be Reformed?

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The total cost of health care in the United States is roughly 18% of Gross Domestic Product, almost twice as much as for any other country in the world.  It is common knowledge that health care entitlements such as Medicare and Medicaid are huge budget busters for the federal government and are a big reason why it is so difficult to get government spending deficits under control.  But the cost of private health care is also increasing rapidly and is a big contributor to the stagnation of middle class income in recent years.  In other words, the exorbitant cost of health care has a negative effect on the entire American standard of living and the problem is just getting worse and worse.
Everyone who is concerned about this problem should read David Goldhill’s new book: “Catastrophic Care:  How American Health Care Killed my Father – And How We Can Fix It” and can start with his article in the September 2009 issue of the Atlantic Monthly. He has an approach which should appeal to liberals and conservatives alike.  All American citizens would be covered from cradle to grave but “health care is fundamentally best left to the market to maximize innovation, quality and efficiency”.  The basic principle is that insurance would only be used to cover real risk rather than the certainties of life such as routine illness and the infirmities of old age.
This ideal is accomplished with a “Balanced Health System: health accounts, health loans, and catastrophic insurance with a very high deductible”.  Of course it will be complicated to switch over an entire health care system to a new operating framework.  Of course there are thousands of details to work out.  Of course there will be strong criticism of any such concrete recommendation for radical change.
The point is that our current system is unsustainable.  Do we change it in a deliberate, rational manner or do we rather delay until a fiscal crisis of some sort occurs?  It is encouraging that our national leaders are working together on such issues as immigration reform and stricter gun control.  But our economic and fiscal problems are much worse and more urgent than these social issues.  We need leaders who have the vision and capability to move us forward on addressing our most fundamental problems.

Why Medicare is Such an Enormous and Urgent Fiscal Problem, II

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The National Institute for Health Care Management has just issued a report, “Health Entitlement Spending: A Story in Six Charts”, which describes in great detail why federal health care spending is such an enormous fiscal problem.  First of all, health care spending is already 21% of total federal spending in 2012.  This spending will more than double in the next ten years.  Annual Medicare expenditures are already double the revenue received from the Medicare Part A Payroll Tax and premiums paid by Medicare recipients.  This gap will continue to steadily widen in the coming years because recent retirees will only pay in total a small fraction of their lifetime benefits.
Every year since 2006, the Medicare Trustees have issued a determination of “excess general revenue Medicare funding”.  By law the President must respond by submitting legislation to correct the problem and Congress must likewise respond on an expedited basis.  But no corrective action has been taken so far.
All federal programs should operate efficiently and much can and should be done to achieve greater efficiency across the whole spectrum of federal programs.  But Medicare is the “sine qua non”, (without which, nothing) for spending reform.  Nothing else matters unless we can get Medicare spending under control.
One way would be to raise Medicare Part A taxes for everyone and also raise premiums for well-to-do Medicare recipients.  And then we’d still have to severely restrict Medicare benefits.  This would be drastic action indeed.
Another way is to give (refundable) tax credits to everyone who applies for Medicare and let them find their own insurance coverage on the private market.  This would create a huge incentive for recipients and their families to pay close attention to health care costs.
Each of the above alternatives would bring radical changes to our Medicare system.  But either we act now in a deliberate, and hopefully rational, manner or else our national debt will grow so rapidly that there will be a new fiscal crisis much worse than what happened in 2008.
Which of these three scenarios do we prefer?  Right now we have a choice!

Why Medicare Is Such an Enormous and Urgent Fiscal Problem

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An article in today’s (April 4, 2013) New York Times, “Misperceptions of Benefits Make Trimming Harder”, explains why Medicare is such an enormous and urgent fiscal problem for the federal budget.  The article points out that an average single male who retired in 2010 will receive more than $100,000 in Medicare benefits in excess of what he pays into Medicare in taxes before retirement and premiums while receiving benefits.  The gap is projected to grow for future retirees.  Too many people are not aware of this huge discrepancy between what they pay into Medicare compared to the benefits which they will draw out after retirement.
According to the reporter, Democratic leaders, including the President, are aware of this funding gap but are unwilling to discuss it publicly.  Instead they take the easy way out by criticizing Republicans who do want to address the problem in a responsible manner.
The problem is so serious that trims around the edges, such as means testing and/or higher premiums for affluent retirees, will not accomplish anything more than making a small dent in the funding gap.  Raising taxes will not get the job done either because they would have to go up too much and too often as the problem keeps getting worse and worse.
The only way to really solve the problem is to control the costs of Medicare (and more generally for all of health care).  There are two basic ways to do this.  One way is to have a government run single payer system with very strict rationing.  The other way is to make everyone, including seniors, financially responsible for their own health care, with subsidies for people with low incomes.
The challenge for Republicans is to frame this basic choice as clearly and vividly as possible.  The American people must come to realize that the status quo in health care cannot continue.  If this message can be delivered effectively to the broad public, I am confident that a majority of people will want a free market system with choice rather than severe government rationing.

Why is Healthcare so Expensive?

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Time Magazine has just published its longest article ever, a 25,000 word piece by Steven Brill, entitled Bitter Pill: Why Medical Bills Are Killing Us.  The article contains one example after another of outrageous medical bills being charged to people who are the least able to pay, either the indigent or the uninsured.  Mr. Brill’s solution to this horrible mess is for the government, i.e. the bureaucracy now being expanded by the Affordable Care Act, to do a much better job of using its clout to control costs.

But there is another point of view about what is wrong with our healthcare industry and what can and should be done to make it far more efficient and enable it to provide us with quality care at a much lower cost.  David Goldhill provides a roadmap to a consumer-driven healthcare system with his new book, Catastrophic care: How American Health Care Killed My Father and How we Can Fix It. 

Mr. Goldhill’s proposal is to introduce true competition, not quasi competition dictated by over-burdensome bureaucratic rules, into the American healthcare system.  In other words, let the marketplace figure out what works best by trial and error, rather than expecting even the brightest and most well-meaning experts to be able to figure it out a-priori.  There would still be massive government sponsored programs, such as cradle-to-grave catastrophic insurance and mandatory health accounts, to provide universal care for all.  But the myriad details would be left to the consumers and providers of healthcare to work out over time.

The healthcare crisis in the United States is not just about controlling the rapidly increasing costs of Medicare and Medicaid, as serious as this problem is.  It is also about controlling the costs of private healthcare which is retarding the growth of prosperity for the entire middle class.  Fundamentally we have two basic ways to proceed. We can either move toward a single payer government run program, like much the rest of the developed world, or we can set up a minimally controlled (to insure universal access) system where each of us has the primary responsibility for our own health.