The Republican Health Care Muddle

 

The Republican Party is facing resistance from both the left and the right as it tries to undo key provisions of the Obama administration’s Affordable Care Act (ACA) of 2010. Even if the current GOP bill, called the American Health Care Act (AHCA), bites the dust, some changes will surely have to be made, so the only question is which ones and why. President Trump’s demands for the bill are unhelpful: “Affordable coverage for everyone; lower deductibles and health care costs; better care; and zero cuts to Medicaid.” No responsible reforms can meet these populist expectations.

The only way to move the debate forward is to consider the first principles of health care economics. Any sensible health care reform has to simultaneously (1) reduce costs, (2) ensure better access, and (3) provide higher quality care. There is an obvious tension among these goals. The best way to raise quality, for example, is to invest more resources in health care, which could raise costs and reduce access. It looks as though no one government program could meet all three goals at once.

Yet what is left out of this account is the role of innovation in expanding health care choices. Market solutions to health care problems are widely derided for stripping vital services from the poor to line the pockets of the rich. But the obsession with redistribution overlooks how new forms of health care services—which rely on choice, competition, and deregulation—can drive down costs, while improving both quality and access.

Market-based innovations are driven by the threat of entry and exit. Thus, a producer that holds the dominant position in the market can be undercut by a new entrant that offers a mix of lower prices and higher quality to its customers. Some competitors streamline traditional forms of services. Others replace traditional insurance plans with “concierge” medicine, walk-in clinics, or both. The incumbents, who are well aware of that risk, in turn push to reduce costs and increase quality in order to maintain their customer base. All players, both current and potential, are, thus, constantly attuned to the need to make improvements to all three elements of the health care equation, without any form of government subsidy. With open entry, the level of product differentiation in health care markets will start to resemble those available for other consumer goods. All consumers do not purchase food, clothing, shelter, transportation, or internet services of the same quality level, or in the same way. With time, innovation lets consumers at the bottom of the market get services that formerly were available only to people at the upper end of the market. Just think of how services have expanded in telecommunications. And, if the level of competition gets too stiff, the weaker firms can exit the market, which in turn reduces the cost pressures against the firms that remain.

This market-based process never works seamlessly, but government subsidies that rescue weak technologies or firms from their deserved extinctions are not the answer. And those subsidies, moreover, never come cost-free, for the subsidies generate tax and regulatory burdens that hamper other players in the system. Indeed, one of the great failures of the ACA was that it relied on a suite of selective taxes, most notably on medical devices, that had two dire consequences. First, they distorted the operation of these collateral markets. Second, they avoided the political resistance that comes with directly taxing voters—a powerful check on any new government program. The result was bigger health care subsidies, which today have become ever harder to root out. At this point, there is a clear strategy for lawmakers to follow. First, try to remove all the inefficiencies in the current system, and only then experiment with various programs of subsidy and taxation to correct the remainder.

One objection to this market approach, often raised in health care settings, is that consumers lack the necessary information to make intelligent health care choices. But there are a number of responses to this. First, the overall levels of knowledge are highly variable among consumers. To be sure, many people will remain ignorant about what choices they can make, and they may lack critical information or be unable to act on it. But those people who can make adjustments have an incentive to acquire knowledge that will lead to better choices, including gaming the ACA. They don’t need to rely solely on their own expertise. There are all sorts of third parties and websites to which they can turn to acquire the needed information. Oftentimes, they are part of larger groups—as employees of organizations, for example—that have agents who can help. The information gap can never be entirely closed, but it surely can be narrowed. Consumers tend to make sensible choices in areas for which they have no insurance, such as cosmetic surgery or veterinary care, after all.

The second objection—that markets do not help those who cannot afford the services at all—is more difficult to handle. In some cases, the difficulty lies with the consumer’s lack of funds. In other cases, it stems from the high cost of the services, which rise steeply with age. How, then, to fill the gap, especially for services needed in life-threatening situations? The traditional methods relied on a mix of strategies for limited cross-subsidies. Some physicians offered services at little or no cost; various charitable institutions filled in the gap; and modest government programs offered barebones assistance. This collection of stopgap measures was not perfect, but it was not futile either. The increases in life expectancy between 1900 and 1965 (the year before Medicare) were dramatic, from 47.3 years in 1900 to about 70.3 years in 1965, very little of which was attributable to government support of health care.

Nonetheless, over the past 50 years, government cross-subsidies are now formally embedded through Medicare, Medicaid, and the ill-fated health care exchanges, which in combination have driven out many private plans that were in fact economically viable. At this point, it is difficult to root out large subsidies on which people of advanced age have come to rely. Retirees cannot be expected to go back to the market under a new set of market-oriented rules. Bad systems are hard to undo.

An example is this: The ACA contained a statutory limitation providing that insurance carriers could only charge their most expensive patients (those pre-Medicare patients between 50 and 64) three times what they charged their least expensive patients (roughly those in their 20s). Since the insurance carriers can only make money if they enroll a large group of low-cost customers, the patient mix is critical in these health care markets. Note that this source of plan instability never arises in a purely voluntary market that bleeds out all cross-subsidies, by accurately pricing risk. The voluntary insurance pool remains stable no matter what its composition by age because the insurance company makes a profit on each customer. Not so with the ACA, for now some provision has to be made to prevent some firms from going out of business, given that they are required to offer substantial subsidies to some of their customers. The ACA exchanges have largely broken down, as insurers both large and small have withdrawn from the system because of their inability to make money under the current rules. The failure is an object lesson of the dangers of cross-subsidies.

One design feature of the ACA was to impose a set of cross-payments from those firms that had a better book of business to those firms that did not. Unfortunately, that system only works, if at all, if some of these companies are able to turn a profit from their insureds. However, it was wholly unrealistic to expect companies that were losing money to make payments to other companies with even greater losses. Hence the government sought to make up the shortfall by charging the general judgment fund of the United States, for which there is no clear statutory authority and a manifest disagreement among federal judges as to whether these additional payments were legal under the ACA—a matter that will take years to resolve, leaving everyone in limbo in the interim.

In an effort to reduce the sting to the transfer program, the Republican bill allows for the introduction of a five-fold difference in premium rates from the bottom group to the top group. This greater differential will stem the outflow of insureds among the younger group. The size of the effect is anyone’s guess, for no one knows how permanent the change will be. Yet at the other end of the market, the removal of the subsidy creates financial pain among older individuals who now face higher insurance premiums. The Republican legislation contains some additional support to offset the size of the cross-subsidy, but the AARP estimates treat the cash subsides as too little, too late. The lesson is that once a subsidy is embedded in the system, it becomes a strong entitlement of its own. It is far easier to stop the introduction of a new subsidy than it is to remove it once in place.

The battle over redistribution should prompt both sides to find some way to wring inefficiencies out of the current system. But here a key design mistake in the Obama bill complicates things. The ACA rigidly structures all activities of participating carriers on its exchanges. The latter should look more like platforms on voluntary exchanges like eBay, whose operator does not seek to set terms of exchange, but only to enforce the terms that the parties choose for themselves. The ACA exchanges, however, impose all sorts of misguided substantive restrictions on the terms of these trades. They have high definitions of minimum essential benefits, many of which have no parallel in any voluntary markets. The exchanges require state and federal officials to review the price terms. They limit the total amount of expenditures that can be made for “administrative expenses,” making it difficult for insurers to recruit new enrollees or introduce other cost-effective plans to reduce the risk of illness or injury. And they invite opportunism by allowing people to sign on just before they need services, which has taken its toll: low-risk persons flee the plans to which high-risk persons of all ages flock.

The plans were a prescription for failure. No wonder that the enrollment projections of the Congressional Budget Office (CBO) for 2017 have run high—at about 24 million, compared to the current base of 12.2 Million. But the CBO blockbuster projection—namely that “the number of uninsured Americans would increase by 14 million in 2018 and rise to 24 million in a decade” as a result of the Republican bill, is shutting down the discussion before it can begin. That one number may well doom the current version of the AHCA. Perhaps that is a blessing in disguise. What the Republicans need to do is to figure out how to make the current system more efficient, for otherwise they will lose the next major battle over redistribution.

© 2017 by the Board of Trustees of Leland Stanford Junior University

Published in Healthcare, Law
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Members have made 16 comments.

  1. Profile photo of Goldwater's Revenge Member

    Sorry but in all this I missed the part about Tort Reform. For decades physicals have been forced to practice CYA medicine, prescribing unwanted and unnecessary lab tests just in case. Insurance companies pay frivolous law suits rather than go to court knowing judges will allow the case to drag on for years. Winning a defendable case costs more in legal fees than paying the claim. This only encourages future litigation from unscrupulous attorneys.

    Has anyone calculated what percentage of each insurance premium goes to cover legal fees? I suspect the number would be shocking. No meaningful health care plan will be successful without tort reform.

    • #1
    • March 20, 2017 at 4:34 pm
    • Like0 likes
  2. Profile photo of Spin Coolidge

    Get rid of the lines around the states!

    • #2
    • March 20, 2017 at 5:01 pm
    • Like0 likes
  3. Profile photo of MarciN Member

    Richard Epstein:Yet what is left out of this account is the role of innovation in expanding health care choices. Market solutions to health care problems are widely derided for stripping vital services from the poor to line the pockets of the rich. But the obsession with redistribution overlooks how new forms of health care services—which rely on choice, competition, and deregulation—can drive down costs, while improving both quality and access.

    Market-based innovations are driven by the threat of entry and exit. Thus, a producer that holds the dominant position in the market can be undercut by a new entrant that offers a mix of lower prices and higher quality to its customers. Some competitors streamline traditional forms of services. Others replace traditional insurance plans with “concierge” medicine, walk-in clinics, or both. The incumbents, who are well aware of that risk, in turn push to reduce costs and increase quality in order to maintain their customer base. All players, both current and potential, are, thus, constantly attuned to the need to make improvements to all three elements of the health care equation, without any form of government subsidy. With open entry, the level of product differentiation in health care markets will start to resemble those available for other consumer goods.

    Well said.

    • #3
    • March 20, 2017 at 6:32 pm
    • Like1 like
  4. Profile photo of Spiral Coolidge

    Goldwater's Revenge (View Comment):
    Sorry but in all this I missed the part about Tort Reform. For decades physicals have been forced to practice CYA medicine, prescribing unwanted and unnecessary lab tests just in case. Insurance companies pay frivolous law suits rather than go to court knowing judges will allow the case to drag on for years. Winning a defendable case costs more in legal fees than paying the claim. This only encourages future litigation from unscrupulous attorneys.

    Has anyone calculated what percentage of each insurance premium goes to cover legal fees? I suspect the number would be shocking. No meaningful health care plan will be successful without tort reform.

    Tort reform would require 60 votes in the US Senate, which means tort reform would require 8 Senate Democrats and all 52 Republicans in order to end a filibuster.

    Real health care reform will never be possible until the legislative filibuster is eliminated.

    • #4
    • March 21, 2017 at 1:48 am
    • Like0 likes
  5. Profile photo of RyanFalcone Member

    I think a filibuster can be defeated by forcing their hand and just patiently waiting for them to exhaust themselves on the floor. It may take weeks but it would be worth it. The problem has not been the filibuster. The problem has not been progressives fighting for their principles. The problem has been decades of conservatives not having any principles.

    • #5
    • March 21, 2017 at 4:37 am
    • Like1 like
  6. Profile photo of bridget Member

    The second objection—that markets do not help those who cannot afford the services at all—is more difficult to handle.

    Markets do not immediately help those who cannot afford the services at all, but in a free-market system, those services inevitably become far less expensive and more available. There are plenty of people who cannot afford a $300 doctor’s visit, or a $700 emergency room visit, but can afford a $99 Minute Clinic visit. Technology will make things less expensive over time (in a free market system), and reducing regulatory overhead benefits everyone.

    Moreover, the interference of the government actually creates a system wherein charitable medical care is problematic. The government must get the “best price” for the goods and services it purchases – a sensible precaution to ensure that taxpayers are not getting hosed – but one that comes with the unintended effect of making it hard for companies, hospitals, and physicians to give a lower price to those who can only afford some of it.

    It should be obvious how a more free-market system would help those people.

    • #6
    • March 21, 2017 at 7:24 am
    • Like4 likes
  7. Profile photo of bridget Member

    Has anyone calculated what percentage of each insurance premium goes to cover legal fees? I suspect the number would be shocking.

    From what I recall, about one or two percent.

    But the legal fees aren’t what drives the cost (believe it or not). The cost is driven by the sheer volume of CYA medicine, which in turn triggers more review and restriction by insurance companies; that, in turn, triggers a host of overhead costs (which are built into premiums) and more state and federal regulation (to prevent evil insurance companies from killing people by denying necessary procedures).

    If people had to pay out of pocket for CYA medicine, most of the costs would go away. That’s why low-premium, high-deductible plans paired with HSAs or FSAs are actually proven to reduce medical spending (with similar health results and patient satisfaction).

    • #7
    • March 21, 2017 at 7:29 am
    • Like3 likes
  8. Profile photo of Mike H Thatcher

    Cut Medicine in Half

    • #8
    • March 21, 2017 at 7:43 am
    • Like1 like
  9. Profile photo of MarciN Member

    bridget (View Comment):
    Markets do not immediately help those who cannot afford the services at all, but in a free-market system, those services inevitably become far less expensive and more available. There are plenty of people who cannot afford a $300 doctor’s visit, or a $700 emergency room visit, but can afford a $99 Minute Clinic visit. Technology will make things less expensive over time (in a free market system), and reducing regulatory overhead benefits everyone.

    Moreover, the interference of the government actually creates a system wherein charitable medical care is problematic. The government must get the “best price” for the goods and services it purchases – a sensible precaution to ensure that taxpayers are not getting hosed – but one that comes with the unintended effect of making it hard for companies, hospitals, and physicians to give a lower price to those who can only afford some of it.

    It should be obvious how a more free-market system would help those people.

    This is all so true. I have never heard anyone say this so well and so accurately. I don’t know why you know this, but I’m impressed that you do. 🙂

    • #9
    • March 21, 2017 at 10:48 am
    • Like2 likes
  10. Profile photo of bridget Member

    MarciN (View Comment):

    bridget (View Comment):[….]

    It should be obvious how a more free-market system would help those people.

    This is all so true. I have never heard anyone say this so well and so accurately. I don’t know why you know this, but I’m impressed that you do. 🙂

    Thank you. 🙂

    Um, health care law & financing courses in law school? And I won’t out myself by describing post-law school activities (as readily available as such information is to those remotely adept with google).

    • #10
    • March 21, 2017 at 12:14 pm
    • Like3 likes
  11. Profile photo of Chris Campion Thatcher

    bridget (View Comment):

    Has anyone calculated what percentage of each insurance premium goes to cover legal fees? I suspect the number would be shocking.

    From what I recall, about one or two percent.

    But the legal fees aren’t what drives the cost (believe it or not). The cost is driven by the sheer volume of CYA medicine, which in turn triggers more review and restriction by insurance companies; that, in turn, triggers a host of overhead costs (which are built into premiums) and more state and federal regulation (to prevent evil insurance companies from killing people by denying necessary procedures).

    If people had to pay out of pocket for CYA medicine, most of the costs would go away. That’s why low-premium, high-deductible plans paired with HSAs or FSAs are actually proven to reduce medical spending (with similar health results and patient satisfaction).

    Heath insurance premiums don’t pay the liability insurance of the provider – the provider’s costs are rarely covered in any sort of line-by-line matchup.

    Hospitals frequently use captive insurance to cover their anticipated liabilities from lawsuits. Those are costs the hospital bears, and inevitably wind up as part of billing in some way, shape, or form, and probably only partially.

    The other thing is that most hospitals (at least at the one I worked in) gave away free care, or charitable care, as it was known. These are essentially charges for uninsured or partially insured that the hospital knows it is never likely to recover. I think they’re calling it “uncompensated care” in this 2015 budget snapshot, to the tune of $57MM.

    For perspective – they essentially write off, as a loss, what their net operating margin is. A margin of 4.7% (margin/net operating revenue). They give away, annually, an amount equal to profit (not truly profit as is understood in a for-profit entity, but you get the idea).

    • #11
    • March 21, 2017 at 6:24 pm
    • Like0 likes
  12. Profile photo of bridget Member

    Heath insurance premiums don’t pay the liability insurance of the provider – the provider’s costs are rarely covered in any sort of line-by-line matchup.

    Say what?

    If a provider’s costs go up (higher rent, higher insurance premiums, more costs to bill the insurer because the forms are more complex, whatever), he has two choices: (1) reduce profit*, or (2) increase prices.

    Those increased prices mean the insurer is charged more, who then… drumroll… either increases premiums or reduces profit.

    Eventually, increased costs all get cycled back to the payer (us) in some form or another: increased premiums, increased co-pays, increased deductibles, or decreased access or quality.

    *For the sake of clarity, “profit” is in the “revenue minus costs equals profit” sense, not in the “profit versus non-profit hospitals” sense.

    • #12
    • March 22, 2017 at 7:43 am
    • Like2 likes
  13. Profile photo of bridget Member

    The other thing is that most hospitals (at least at the one I worked in) gave away free care, or charitable care, as it was known. These are essentially charges for uninsured or partially insured that the hospital knows it is never likely to recover. I think they’re calling it “uncompensated care” in this 2015 budget snapshot, to the tune of $57MM.

    My understanding – correct me if I am wrong – is that the hospital cannot give those write-offs in advance. It cannot (as therapists often do) have a sliding scale for payment that it posts in advance; rather, it must provide the care, charge the patient the full value of the care, chase the patient for money, determine that the patient cannot pay, potentially screw up the patient’s credit, and then write it off.

    While there are federal requirements for hospitals to provide care to low-income patients, many patients do not qualify. Aside from the problem that many people can’t pay and can’t qualify, and the difficulties in navigating the process, it’s basically a mandatory exception to a mandate. That’s not how you develop a free market.

    Those are not, IMHO, equivalent.

    • #13
    • March 22, 2017 at 7:51 am
    • Like3 likes
  14. Profile photo of RktSci Member

    Goldwater's Revenge (View Comment):
    Sorry but in all this I missed the part about Tort Reform. For decades physicals have been forced to practice CYA medicine, prescribing unwanted and unnecessary lab tests just in case. Insurance companies pay frivolous law suits rather than go to court knowing judges will allow the case to drag on for years. Winning a defendable case costs more in legal fees than paying the claim. This only encourages future litigation from unscrupulous attorneys.

    Has anyone calculated what percentage of each insurance premium goes to cover legal fees? I suspect the number would be shocking. No meaningful health care plan will be successful without tort reform.

    Tort reform is a state issue, by and large. Some states have enacted it and malpractice premiums went down. My wife’s went down by 50% after our state enacted such a law. Her carrier had a policy of fighting frivolous claims rather than paying them, as did many other carriers. They refused to pay Danegeld. The true cost is not the legal fees in fighting, but the time lost by the physician in depositions, meetings, etc. In addition, there is the strain caused by the lawsuit, which can take years to resolve.

    • #14
    • March 22, 2017 at 8:04 am
    • Like1 like
  15. Profile photo of RktSci Member

    bridget (View Comment):
    My understanding – correct me if I am wrong – is that the hospital cannot give those write-offs in advance.

    There are ways to do this. If a patient doesn’t qualify for Medicaid or other insurance programs, many teaching hospitals have programs where a limited number of patients can qualify for acute care. A family member that was in such a position got a heart procedure done. However, the general rule is that your lowest price is what you charge Medicare/Medicaid – to charge anyone less is a felony.

    The fee schedules of Medicare and Medicaid are the equivalent of telling grocers that they have to let food stamp recipients get food items for 30-50% off. And nobody can get a cheaper price.

    • #15
    • March 22, 2017 at 8:14 am
    • Like1 like
  16. Profile photo of Ralphie Member

    Mike H (View Comment):
    Cut Medicine in Half

    Thanks for the link.

    • #16
    • March 29, 2017 at 6:54 pm
    • Like0 likes