As I discussed in my last post, the Congressional Budget Office has shown very clearly that the U.S. is on an unsustainable fiscal path which must be reversed in order to avoid calamity. We are spending too much money and not taking in enough tax revenue. In a recent Wall Street Journal Op Ed column, the economist Martin Feldstein describes “How to Create a Real Economic Stimulus”. “A successful growth and employment strategy would combine substantial reductions in the relative size of the future national debt with immediate permanent tax rate cuts and a multiyear program of infrastructure spending…….The only way to reduce future deficits without weakening incentives and growth is by cutting future government spending.”
Mr. Feldstein proposes slowing the growth of benefits of middleclass retirees by gradually raising the full benefit retirement age for Social Security from 67 to 70 and also raising the age of Medicare eligibility to the same level. This would create a budget savings of 1% of GDP, or $200 billion, by 2020. Rather than eliminating such popular tax deductions as the one for mortgage interest or the exclusion of employer payments for health insurance, he recommends limiting the amount by which individuals can reduce their tax liabilities to 2% of adjusted gross income. This single change to the tax code would, for example, reduce the 2013 deficit by $140 billion.
In addition to lowering tax rates for individuals, corporate tax rates should be cut from 35% to about 25% in order to be competitive with other industrial countries. We should also adopt the internationally common “territorial” system which doesn’t tax foreign earnings brought back home.
In short, we decrease spending and raise revenue with entitlement reforms and a limit on tax expenditures thereby creating a framework for tax rate reductions and infrastructure spending. These are the sorts of bold measures needed to produce a real stimulus and thereby get our economy back on track!
Yesterday’s Wall Street Journal has a very interesting article, “More Employers Overhaul Health Benefits”, which describes a movement just getting started whereby employers give their employees a fixed sum of money and let them choose their own plan from an online market place. The idea is that employers will be better able to predict and control their healthcare expenses for employees. Furthermore, employees will be able to get better value for dollars spent by selecting their own coverage options, deductible amounts, copays, etc.
In fact, in an exchange run by Liazon Corp., which has 60,000 people enrolled, 75% of workers have chosen less expensive plans than they had before, by accepting bigger deductibles and copays, as well as smaller choices of healthcare providers and restrictions such as primary-care gatekeepers.
This is such an appealing approach to private healthcare cost control that the Accenture Management Consulting Company estimates just five years from now there will be 40,000,000 business employees receiving their healthcare benefits in this manner. This would be a phenomenal development!
The United States spends 18% of GDP on healthcare altogether, both public and private, which is double the amount spent by any other country. This enormous expense is a major reason why wage growth is stagnant in our country as well as why the costs of public programs like Medicare and Medicaid are so high and contributing to so much government debt. It is critical for our country to get the rapid increase of healthcare costs under much better control. That’s why this new movement of employers and employees working together on this critical problem is such a big step in the right direction.
If the estimate by Accenture is anywhere nearly accurate about how fast this new private healthcare selection method will grow, then there will soon be an excellent opportunity for Congress to expand its benefits to the control of Medicare and Medicaid costs as well. This is very exciting indeed!
Scott Lilly, a Senior Fellow at the Center for American Progress, has an Op Ed column in yesterday’s Fiscal Times, “The Choice Congress Won’t Face Up To”. Mr. Lilly admits that we have at least a long-term deficit problem, namely exploding entitlement spending driven by the aging of the U.S. population. The Congressional Budget Office predicts that federal outlays, including entitlements, will be 22.8% of GDP in 2023 while revenues will equal only about 19.3% of GDP, a huge gap. And outlays will continue to rise, because of entitlement spending, reaching 25% of GDP by 2040. This means that the public debt, on which we pay interest, would rise from 73% of GDP today, to 99% of GDP by 2040. As interest rates inevitably return to their historical average of 5%, interest payments on this massive debt will become an increasing burden on the economy.
Mr. Lilly asks the question: How are we going to cut back on entitlement spending when the average Social Security monthly check is $1268 out of which about $350 goes to out-of-pocket medical expenses not covered by Medicare? Congressman Ryan has proposed limiting the growth of Medicare to the increase of inflation + 1%. But the cost of healthcare is increasing much faster than this. And many seniors are living close to the edge.
Thus we reach “the choice which Congress won’t face up to.” According to Mr. Lilly, either we have to make big cuts in entitlement spending or else raise taxes dramatically so that federal revenue increases to about 24% of GDP by 2040. Mr. Lilly makes the far-fetched claim, based on flimsy evidence, that such a large tax increase will not retard economic growth. But let’s set this issue aside for now.
Is there any alternative to increasing taxes so dramatically in order to avoid making big cuts in entitlements? The answer is yes. The above discussion assumes that the cost of healthcare in general will keep on increasing at the current rapid rate, much faster than the increase in inflation. This is the main driver of entitlement costs. The U.S. currently spends 18% of GDP on healthcare which is double the amount spent by any other country. This is what must change. We should abolish, not just postpone, the employer mandate in Obama Care. But even more fundamentally, the tax exemption for employer provided healthcare should be removed (and offset with a rate reduction). This would make consumers far more aware of the cost of healthcare and therefore drive down these costs.
Only after serious attempts are made, such as above, to control costs should any consideration be given to raising taxes.
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!
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!
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!