To reduce earnings inequality, we must first reduce healthcare insurance coverage costs

Given the tremendous amount of focus on income inequality these days and the common knee-jerk reaction to push harmful and counterproductive wealth redistribution policies as a palliative, it is timely and important that Mark Warshawsky of the Mercatus Center at George Mason University recently published a working paper exploring the largely heretofore ignored impact to earnings inequality of employer-based healthcare coverage as a component of total compensation.

The punchline is this: healthcare coverage costs have consistently risen faster than wages for most Americans over the past four decades. Given that healthcare coverage is relatively equal across the income ranges (it is roughly the same cost to an employer to cover a family of four in the lower 30th decile of earners as that of a family of four in the highest 10th decile of earners), rising healthcare costs will harm and encroach more grievously on the employer’s ability to increase take home earnings for lower income earners. In other words, increasing healthcare costs, even if growing at the same rate for lower income workers as higher income workers, will eat up more of a percentage of total compensation and restrain actual take-home earnings for lower income workers. Furthermore, most studies, including the high- visibility and high impact to public policy book by Thomas Piketty, Capital in the Twenty-first Century, have used after-tax earnings data to compare wealthy and poor, resulting in loud alarm bells on inequality. The impact? Politicians across the globe, including President Obama, declared income inequality the defining issue of our time, but based upon partially constructed data! Warshawky’s research more appropriately focuses on total compensation, which provides a more comprehensive assessment of what is going on, and in this picture is revealed a more tightly coupled growth between the income poles. This is not to say that inequality in earnings is not a problem we should address, it is more to say that policies to address it should focus on the actual cause – which is not the perceived ability of the wealthy to extract wealth at the expense of the poor, but a direct result of the pernicious impact of rising healthcare coverage costs that crowd out earnings growth for those in lower income categories.

Warshawsky uniquely pulls directly from the Bureau of Labor Statistics, which provides a full assessment of the total compensation aspects of American workers. Contrast that with most studies’ data sources from the IRS and Social Security that only include cash earnings, and one develops an understanding that Warshawsky has the superior data set. In previous research using BLS data from 1999-2006, Warshawsky was able to demonstrate that if it had not been for increases in healthcare coverage costs, earnings growth between income levels would have been roughly the same. In order to understand and present the data more clearly and in layman’s terms, I have taken Warshawsky’s data and plugged in and extrapolated where I could while backing into implicit assumption numbers on baseline earnings, healthcare coverage costs, and fringe benefits for middle decile income and comparing them to top 1% incomes from 1999-2006. The patterns revealed are that while overall total compensation increased in the same percentage range over the course of seven years (34% for middle income earners and 36% for high income earners), the differences were more substantial and divergent within the earnings and healthcare coverage components of total compensation. Whereas for middle income earners wages increased only 3.5% per year, wages increased by 4.4% per year for high-income earners. This may not seem like much for any given year, but over time the differences become pronounced – over the course of seven years, the compounded gain for high income earners was 35% growth in take home earnings compared to only 27% for lower income earners. The key constraint in earnings growth for middle income earners is the fact that healthcare coverage costs rose much faster as a percentage of total compensation – rising at an annual rate of 9.9% compared to a more modest 6% for higher income levels. As Warshawsky indicates, this meant a rise in healthcare coverage as a percentage of total compensation for middle income earners from 7.2% in 1999 to 10.4% by 2006. In comparison, higher wage earners saw a modest increase of 4.0% to 4.3%.Graphs 1 and 2 visually show the impacts. While the slopes of the topline are similar between the two income groups (both rising at annual rates just over 4%), the relative mix of earnings, healthcare coverage, and fringe benefits is dissimilar; healthcare coverage costs are constraining earnings increases for middle income earners. Graphs 3 and 4 represent the percentage of total compensation aspects of the different components of total compensation, further visual evidence of the forces at play here – healthcare coverage increases for middle income earners takes up a larger percentage of total income and constrains earnings growth.

Graph 1

middle-income-total-compensation

Graph 2

high-income-total-compensation

Graph 3

middle-income-compensation-components

Graph 4

higher-income-compensation-components

For anyone interested in a more fulsome review of the examples and scenarios I have created on top of Warshawsky’s values, I have attached the spreadsheet at health-care-costs-inequality. The detailed numbers simply provide another view in support of what Warshawsky states in the working paper, “Though rising healthcare costs eat away at wage growth for everyone, the effects will be largest for the working and middle classes because their healthcare costs are so large relative to the rest of their compensation package.”

In the rest of the paper, Warshawsky provides empirical evidence updates dating through 2014 using the same BLS approach as well as discussing supporting and conflicting studies. The conclusion is the same as the data above that cuts off in 2006, so I won’t drone on at length on it here. The policy implications are much the same as well – relief from healthcare coverage costs and decoupling health insurance from employer-based coverage, allowing American citizens to demand and receive higher wages with which they can then decide how to spend will do more for the lower and middle classes than any economically distorting wealth redistribution program.

 

 

 

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“How to Cure Health Care” – Milton Friedman’s 2001 essay on the subject is still remarkably relevant

If I suddenly discovered that I had a serious disease and was handed a medicine concocted in 2001 as the only antidote available, I would very likely panic, despairing that surely something more timely and up to date could have been developed in the intervening 15-16 years. Alas, it seems that America’s healthcare system has been stuck in a reverse funhouse of distorting mirrors for so long, that it is equal parts amazing and depressing to read an essay from Milton Friedman on the subject and discover that the same advice he had for healthcare in 2001 is precisely the advice that would have cured our ailments if only we had followed it. Unfortunately, as he predicted, we did just the opposite, just how we have been doing it for decades since World War II. Thus, for this particular disease, hand me that vial from 2001, because everything else from then on has been cooked up by quacks and witch doctors. The hard medicine from 2001 might be painful to swallow, but it is the right palliative for the long-run.

In the essay, Friedman begins by noting the most important features of modern healthcare. First, there have been major advances in technology and science, which is no bad thing. Second, for several decades we have witnessed rising costs in healthcare relative to overall economic growth on an inflation-adjusted basis. Finally, healthcare features a decreasing satisfaction level amongst both consumers and producers. Within this feature set, Friedman notes that healthcare is unique amongst many other industries in not catalyzing technological advancement to actually lower per unit costs over time.

What distinguishes health care from these industries? Friedman has the answer – government involvement. Unique amongst all industries, healthcare is the only industry in which government plays such a dominating role in the production, financing, and delivering of medical services. And despite the role of the nominal private insurers in the market, I would point out that government finances, whether directly through Medicare and Medicaid, or indirectly through subsidies, a critical mass of over 50% of healthcare finance. Where the government leads on payment models, commercial players, largely structured in local monopolies, inevitably follow, making a mockery of any claims that this is a “market” in any sense of the word. Commercial insurers are not much different than government directed contractors.

The role of third party payment models
Within this doleful narrative, we can firmly point the finger at third party healthcare payment models as the culprit for the out of control expenditures and the mess of unintended consequences we have found ourselves in. And how we got third party payments is another lesson in how one muddled government intervention leads to the need for yet another, building an unsustainable house of cards that always needs one more card stacked on top. In this case, wage controls in the World War II era led employers to provide medical coverage as a benefit to get around controls and to more effectively compete for talent. By the time the IRS got wind of it and attempted to tax these benefits, they had become so popular that Congress intervened to make them a non-taxable benefit. Here is the catch though- the tax exemption was only provided to employers. Any consumer out on the marketplace buying insurance on their own receives no such benefit. Thus, people are conditioned and majorly incented to look for health coverage from their employer. Friedman summarizes the ill logic behind reliance on third party payment models and employer-based insurance:

We have become so accustomed to employer-provided medical care that we regard it as part of the natural order. Yet it is thoroughly illogical. Why single out medical care? Food is more essential to life than medical care. Why not exempt the cost of food from taxes if provided by the employer? Why not return to the much-reviled company store when workers were in effect paid in kind rather than in cash?

The major perverse impacts of employer-based insurance are that people delegate their healthcare provisioning and decision making to entities and individuals ill-equipped to perform those responsibilities. Furthermore, employees inevitably give up the ability to achieve in direct wages what is now siphoned off to healthcare coverage.

Then in the 1960s the U.S. Government enacted Medicare and Medicaid, driving third party payment models across even more populations. What is the logical impact? As Friedman notes, “nobody spends money from someone else as frugally as his own.” The third party administration of healthcare costs means no incentives for the individual to control those costs. As Friedman observes:

Enactment of Medicare and Medicaid provided a direct subsidy for medical care. The cost grew much more rapidly than originally estimated—as the cost of any handout invariably does. Legislation cannot repeal the nonlegislated law of demand and supply: the lower the price, the greater the quantity demanded; at a zero price, the quantity demanded becomes infinite. Some method of rationing must be substituted for price, which invariably means administrative rationing.

Astoundingly, healthcare as a share of our national income has risen from 3 percent in 1919 to close to 20 percent in 2016. To put this in perspective, Friedman comments that in 1946 seven times as much was spent on food, beverages, and tobacco than on healthcare. By 1996, healthcare had passed these collective categories.

What is Insurance? In healthcare, it bears little resemblance to what it typically means

In every other aspect of our lives, insurance means coverage for the catastrophic, long tail events that we never expect to happen but which would wipe us out financially if they did occur. It is the hurricane that reduces our house to rubble or the wreck that totals someone else’s car and puts them in a hospital. In healthcare, government meddling has forced this to become coverage for everything, however routine the expense. Much of this is based upon the employer incentives to move compensation into healthcare coverage, but even more pernicious is government mandates on what health plans must cover. It is analogous to auto insurance covering oil changes by force of government mandates. In this event, we would not marvel at oil change prices spiraling out of control. Similarly, it is little wonder that healthcare costs have exploded; between third party payment obfuscation, administrative bloat, and mandated coverages of all healthcare expenses, it would be an economical gravity defying miracle if costs didn’t explode.

“The Black Hole of Bureaucratization” 

One malignant outcome of third-party based payment systems is the concomitant growth in administrative functions, be it comprised of the administrative state for government programs or administrative bloat from commercial insurers required to finance, provision, deliver, and indeed ration medical care. As Friedman indicates, since the patient no longer has an incentive to care about healthcare costs and since the provider of health services has to worry about whether a certain service is covered by the third-party payer, a middle layer is required. In this model, the physician becomes little more than an employee of the insurer or the government, taking their guidance on what can be performed for the patient. In turn, the patient’s voice is squelched, as they are merely told what can be done within the confines of their plans.

Here is where Friedman delivers what I believe to be one of his most innovative economics insights, what he calls Gammon’s Law – which is defined as bureaucratization that causes both a rise in inputs and expense alongside a decrease in outputs and outcomes. Gammon’s Law is based upon observations of a British physician named Max Gammon, who performed an extensive study of the British National Health Service and noted that in this bureaucratic system that there was both an increase in expenditure as well as a fall in production. He noted that such systems behave like ‘black holes,’ ‘sucking in resources’ and ‘shrinking in terms of emitted production.’

There are some astounding statistics from the U.S. healthcare system that I believe are so shocking that their true gravity is hard for the human mind to grasp and that demonstrates Gammon’s Law at work. Friedman observes that inflation adjusted costs per patient day since 1946 have increased from $30 to $1,200 in 1996. A more recent update for this from the Kaiser Foundation updates this number to $2,200. This is a stonking seventyfold increase! Further highlighting Gammon’s Law at work, hospital staff per bed increased ninefold from 1946 to 1996. Given other trends in the industry, I highly doubt that this force has dissipated in the intervening 20 years. This Hospital Staffing Ratio from Statistica suggests a great amount of staffing per bed in the U.S.

In order to head off any common simplistic conjectures that medical science and technological progress are the reasons for the dramatic increase in inputs and expenditures, Friedman observes the following:

….True, medical machines have become more complex. However, in other areas where there has been great technical progress—whether it be agriculture or telephones or steel or automobiles or aviation or, most recently, computers and the Internet—progress has led to a reduction, not an increase, in cost per unit of output. Why is medicine an exception? Gammon’s law, not medical miracles, was clearly at work. The provision of medical care as an untaxed fringe benefit by employers, and then the federal government’s assumption of responsibility for hospital and medical care of the elderly and the poor, provided a fresh pool of money. And there was no shortage of takers. Growing costs, in turn, led to more regulation of hospitals and medical care, further increasing administrative costs and leading to the bureaucratization that is so prominent a feature of medical care today.

Friedman turns to the important question of what outputs are we getting for this increase in inputs? His answer is that it is almost impossible to tell given overall improvements in diet, clothing, housing, hygiene, sanitation, general improvements in public health, better diagnosis and treatment of conditions, etc. In short, while life span and life expectancy have increased, little of that is likely attributable to the increase in health system spend. In fact, the number of days people spend in a hospital have gone down over time. While obviously that can be a good outcome and a result of better care within the walls of a hospital, it is also directly correlated to cost pressures hospitals face – pressure that leads to a maniacal pursuit of getting patients out of beds and out of the door. In summary, we can’t point to any discernible improvements we have achieved in outcomes to pair with the seventyfold increase in expenditures. Again, Gammon’s Law of the black hole in all of its fearsome gravity sucking power.

Conclusions

In a comparison between the U.S. and other developed (OECD) countries, Friedman articulates that the hybrid system that America employs is particularly bad at controlling costs. In this respect alone, the U.S. has a relative disadvantage compared to peers such as the U.K. and Canada that have single-payer and monopoly over delivery systems. Of course, there is a tradeoff with these systems in access and innovation. Following the previously mentioned maxim on infinite demand when a good is effectively zero, the inherent tradeoff is administrative controlled rationing and inevitable queuing. Another major disadvantage of these systems is that the incentives push politicians to focus less on delivering best-in-class care to a primary focus on controlling costs.

At long last, we have arrived at the palliative against Gammon’s Law in healthcare. Of course, every classical liberal, of which Friedman is an apostle, a veritable “hero of the faith” whom we study and revere, dreams of a healthcare system that becomes as efficient and as consumer-centric as the likes of Amazon. We should be able to get on an intuitive dashboard and observe ratings of physicians and systems on the value that they drive. We should be able to observe both their pricing and outcomes, including being able to drill into the details by condition and procedure of concern to us in that moment. Competition should drive them to provide meaningful information to consumers in order to capture market share. We should have great care-based (not insurance-based) relationships with our primary care providers and other care planners and providers. A classical liberal is going to logically deduce, as does Friedman, that the idealistic path to get there is to eradicate Medicare and Medicaid, remove the tax exemption for employer-based coverage (in return for lower tax rates directly to consumers, of course) and a return of insurance to its proper role of covering catastrophes. Friedman observes that since these are going to be politically impossible in the short-run, we should aim for the next best thing – flexible health savings accounts. Friedman concludes his essay by outlining his policy proposals further:

A medical savings account enables individuals to deposit tax-free funds in an account usable only for medical expense, provided they have a high-deductible insurance policy that limits the maximum out-of-pocket expense. As noted earlier, it eliminates third-party payment except for major medical expenses and is thus a movement very much in the right direction…

…Medical savings accounts offer one way to resolve the growing financial and administrative problems of Medicare and Medicaid. It seems clear from private experience that a program along these lines would be less expensive and bureaucratic than the current system and more satisfactory to the participants. In effect, it would be a way to voucherize Medicare and Medicaid. It would enable participants to spend their own money on themselves for routine medical care and medical problems, rather than having to go through HMOs and insurance companies, while at the same time providing protection against medical catastrophes.

A more radical reform would, first, end both Medicare and Medicaid, at least for new entrants, and replace them by providing every family in the United States with catastrophic insurance (i.e., a major medical policy with a high deductible). Second, it would end tax exemption of employer-provided medical care. And, third, it would remove the restrictive regulations that are now imposed on medical insurance—hard to justify with universal catastrophic insurance.

This reform would solve the problem of the currently medically uninsured, eliminate most of the bureaucratic structure, free medical practitioners from an increasingly heavy burden of paperwork and regulation, and lead many employers and employees to convert employer-provided medical care into a higher cash wage. The taxpayer would save money because total government costs would plummet. The family would be relieved of one of its major concerns—the possibility of being impoverished by a major medical catastrophe—and most could readily finance the remaining medical costs. Families would once again have an incentive to monitor the providers of medical care and to establish the kind of personal relations with them that were once customary. The demonstrated efficiency of private enterprise would have a chance to improve the quality and lower the cost of medical care. The first question asked of a patient entering a hospital might once again become “What’s wrong?” not “What’s your insurance?”

In the aftermath of the surprise election putting Trump in charge of a unified GOP Congress, it is encouraging that the policy proposals developed under the moniker of “Better Way” produced by Paul Ryan and other Republicans in Congress make incremental gains in these areas. I have summarized these policy proposals in another post, and while they don’t go nearly as far as Friedman or I would want, it at least has the advantage of incremental gains, particularly in the area of health savings accounts. Given that Obamacare went even further in the wrong direction compared to Friedman’s prescriptions, further exacerbating the decades of bad decisions full of unintended consequences that is the hallmark of U.S. healthcare policy, getting at least a portion of that proverbial 2001 antidote vial is good momentum. Of course, Trump is the ultimate wild card on where he intends to take healthcare reform, but I hope he looks no further than some of the sensible plans that are already there. The ball is being handed off right in the gut. Don’t fumble it, Mr. President.

As bonus material, it is always a personal pleasure to observe the affable and remarkably quick on his feet Friedman address some of these questions and issues directly. Here are some great videos on this very subject.

The central government planners behave as conflicted madmen, creating a muddle of healthcare

madman

The federal government created the “Affordable” Care Act, which by this point is a laughable misnomer in the face of never ending premium increases, alongside the creation of payment and delivery reform structures such as Accountable Care Organizations, knowing full well that it would drive health system consolidation. In fact, one might argue this consolidation was a specific goal of the reforms in the government planners belief that newly minted behemoths would drive cost down due to scale and drive care quality up through better coordination across the system continuum up. Meantime, the same federal government is also fighting against that urge to consolidate through the Federal Trade Commission, as this Modern Healthcare Article indicates.

If we were to view a man trying to push the walk button at a busy intersection with his right hand while his left hand tugged it back, we would think him a madman. Well, this is our own government intervention into the healthcare “market” at its finest.

Explaining the EpiPen (hint – the company can jack its prices up because of government intervention, not because of the lack of it)

This author does as admirable of a job as any I have seen, so I am sharing it. http://slatestarcodex.com/2016/08/29/reverse-voxsplaining-drugs-vs-chairs/

The only point he leaves out that I would like to make is the laughable hypocrisy of government officials, including one candidate for President, claiming we need more government intervention and price controls. I have a better idea for policymakers – how about trying something that comes completely unnatural to you – get out of the way and let innovators do what you could never do, actually create products that people want at lower cost and higher quality, if only you would let them. I promise it will be more effective and help the poor and middle class a lot more than your prescriptions (lame pun intended.) But I suppose that is the point, your job security is only justified if you are seen as hyperactive in your “protection” of the people. If only the people knew that the only protection we often need is actually precisely from you – the paternalistic functionary.

Here is the key crux of his argument, wrapped into a simple market analogy of chairs:

Imagine that the government creates the Furniture and Desk Association, an agency which declares that only IKEA is allowed to sell chairs. IKEA responds by charging $300 per chair. Other companies try to sell stools or sofas, but get bogged down for years in litigation over whether these technically count as “chairs”. When a few of them win their court cases, the FDA shoots them down anyway for vague reasons it refuses to share, or because they haven’t done studies showing that their chairs will not break, or because the studies that showed their chairs will not break didn’t include a high enough number of morbidly obese people so we can’t be sure they won’t break. Finally, Target spends tens of millions of dollars on lawyers and gets the okay to compete with IKEA, but people can only get Target chairs if they have a note signed by a professional interior designer saying that their room needs a “comfort-producing seating implement” and which absolutely definitely does not mention “chairs” anywhere, because otherwise a child who was used to sitting on IKEA chairs might sit down on a Target chair the wrong way, get confused, fall off, and break her head.

(You’re going to say this is an unfair comparison because drugs are potentially dangerous and chairs aren’t – but 50 people die each year from falling off chairs in Britain alone and as far as I know nobody has ever died from an EpiPen malfunction.)

Imagine that this whole system is going on at the same time that IKEA spends millions of dollars lobbying senators about chair-related issues, and that these same senators vote down a bill preventing IKEA from paying off other companies to stay out of the chair industry. Also, suppose that a bunch of people are dying each year of exhaustion from having to stand up all the time because chairs are too expensive unless you’ve got really good furniture insurance, which is totally a thing and which everybody is legally required to have.

And now imagine that a news site responds with an article saying the government doesn’t regulate chairs enough.

 

 

 

Healthcare isn’t a marketplace

A great summation exhorting us to stop using the term “marketplace” to describe healthcare.

https://www.linkedin.com/pulse/quit-using-word-marketplace-when-you-talk-healthcare-america-hull?trk=hp-feed-article-title-publish

The key point and question that the author goes on to answer is:

A market is a place where buyers and sellers, functioning as independent agents in pursuit of their self interest, meet to negotiate a mutually agreeable exchange of money for products/services.  At Wharton, they taught us, furthermore, that an efficient market has three basic qualities: A critical mass of buyers and sellers, low transaction fees, and information transparency between buyers and sellers.   Do either of those two scenarios remind you of the American healthcare system?

The rest of the post is succinct and on point.

The left’s massive remake of healthcare strikes and fails again

Bagdad Bob.jpg

In a recent Modern Healthcare article, it is evident that small health plans and insurers are being heavily penalized by the ACA’s risk corridor program in a shocking, but not entirely unpredictable, bit of reverse corporate wealth redistribution in which money is actually flowing from small businesses and insurers to the behemoths in the industry such as Anthem and Aetna. Since the ACA and ancillary modern healthcare legislation seems to be openly promoting and favoring the large health system and large insurer over the small private practice and small insurer, this really should not be a surprise. Perhaps it is bringing scarcely disguised huzzahs from those in progressive camps .

Meantime, officials at CMS, in true Baghdad Bob soothsaying fashion, continue to maintain that everything is working to plan. If by working according to plan they mean standing ready to cover and excuse their errors while promising to correct their original mistakes with more thousand page complex and inscrutable reforms (in other words, the standard government playbook of creating a problem through market intervention, blaming venal companies, and then creating more market intervention to further compound the original errors), then I guess they are correct. Meantime, there is less care plan choice due to mandated standardization, less consumer choice of  health providers and insurance companies due to industry consolidation, and precipitously increasing premiums. The next step from progressives is inevitable – proposals that only a single payer health system can resolve this government induced mess. The question to free citizens is, do you really trust the government that can’t build a bridge to manage the entirety of your health insurance system?

Limiting health insurance plan choice is harmful to consumers

A significant component of the Affordable Care Act is the forced standardization of health care coverage through prescribed components that must be carried by insurance plans. Ultimately, this approach has been tremendously disruptive and has moved millions of people off of the plans that in the previous market paradigm they were happy to buy. I refuse to call it a free market since it really has not been that for decades. This disruption is the impetus behind much of the lampooning of Obama’s language, which later proved to be an astoundingly incorrect bit of marketing and hype, that if you had a plan that you liked you could keep it.

Standardization of plans ostensibly removes buyer searching costs for complicated products. Such as approach would only make economic sense if the searching costs were higher than the benefits obtained from the selected product. The challenge is that this sets a remarkably paternalistic precedent – if we dupes in America can’t be trusted to buy health coverage that suits our needs, perhaps we can’t be trusted to buy financial instruments or real estate either. It also has the perverse effect of cutting off product innovation that caters to individuals and unique segments of the healthcare market. Something to consider and question: can government possibly keep up with the changing demands of consumers as well as the unpredictable emergent order that drives market-betterment ideas and innovations? Even if government might be approximately right on the first iteration of defining product standards, it would be impossible for them to keep up with the pace that a free market comprised of consenting adults engaging in commerce could drive. Furthermore, a significant philosophical challenge is that such an approach mandated by government significantly violates an essential freedom of consumers to choose for themselves what is best for them. Finally and perhaps most perniciously, such an approach allows government to enact their own views of desirable social policy through diktat. The Supreme Court case of Burwell vs. Hobby Lobby  is an example in which a private employer was forced to provide contraceptives against their own religious beliefs. Whether one believes Hobby Lobby is outside of the societal norms in their stance on contraceptives is quite beside the point. The point is really whether we believe government should be powerful enough to be able to force anyone in society to choose which product to purchase and what it should contain. This is the first-order principle freedom-loving citizens should be concerned with.

In the book The Future of Healthcare Reform in the United States, Richard Epstein, of the NYU School of Law, pens the following compelling narrative on the challenges with the elitist assumptions of government needing to protect consumers through standardized plans:

Any decision such as that made in healthcare markets – to require given firms to offer a particular type of contract with predetermined coverage – does not facilitate competition but thwarts it by restricting the dimensions over which innovative firms can compete. To be sure, it is unlikely that either midsize firms or ordinary consumers can canvass the entire market. But they can make a series of initial cuts to focus on the market segment they care about most. At this point, one of the key drivers of good competition is the ability to offer a particular configuration of goods and services that make sense to some segment of the overall market. The standardization of service packages thus prevents innovation along certain key dimensions, which hardly improves the overall competitive market. Put otherwise, product differentiation is the great and beneficent spoiler because it allows rapid and discontinuous changes in the market such as the rise and fall of BlackBerry and the now possible decline of Apple in the face of potential disruptive technological developments from a host of competitors. In my view, these large gains dominate any negative effects. Indeed the constant use of product differentiation, both large and small, in market after market, suggests healthcare regulators engage in a dangerous gambit by limiting product choice to a few set choices in order to reduce the buyer’s costs of search. People can truncate searches using sensible strategies. They do not have similar ways to expand market options.

Imagine if government decided that our smartphone choices were overwhelming to consumers and determined that we should all have certain features based upon some government committee’s determination of a rightful specific set of requirements. I suspect the product so described by the committee in the duly published 500 page document would prescribe usage of something resembling the BlackBerry more so than the iPhone. And despite Hillary Clinton’s fondness for this device, we obviously would be immediately worse off as consumers. Further imagine that the government decided that we could no longer buy the phones at Apple stores or Best Buy, but purchasing of these devices had to occur at government licensed locations. Behold the entirety of the healthcare market: a market in which there is an inherent paternalistic assumption that consumers are too ignorant and overwhelmed to make their own choices. The government committee decisions on what we can buy and where we can receive our products described in the smartphone analogy is precisely the kind of marketplace we have allowed our government to create in healthcare. Perhaps it is time to step back and ask ourselves why and whether we are getting good outcomes out of this approach.

 

We are from the government, and while we created this mess, we are here with a 900 page dictate to help

Price is high

Health and Human Services, ever so helpful, is now taking aim at simplifying patient billing, a problem largely of the government’s own creation due to decades-long healthcare meddling (thanks to my friend Bob for the picture above). A HISTalk post on the hypocrisy of HHS taking this challenge on has a quote that captures the essence of the true underlying reasons for the mess in the first place:

This is the height of hypocrisy. Does CMS think providers on their own created the insane billing requirements and processes? It started with Medicare Part A, then B, then D. Co-payments, deductibles, out of network, referral approvals, contractual allowances, UC charges, and on and on. Next, billing systems will have to deal with VBP, P4P, bundled payments, MACRs, and more. Providers never asked or suggested any of these — they just have to figure out how to carve up charges/costs and services and put it all on a one-page bill. A 1995 analysis found that the Federal Register contains 11,000 pages dealing with an IRS 1040 submission, but hospital billing required 55,000 pages to describe. If CMS really wants to simplify the patient bill, they need to go to a single-payer system. Until they do that (not likely), the patient bill will continue to be the mess it has been for the last 50 years. Who do I call to collect my $5k?

Of course, I wholeheartedly disagree with the author’s prescription to create a single-payer health system as a result. He is inviting the wolf that created the mess in the first place farther into the hen-house and proposing making them even more all-powerful and monopolized. Does he really believe that they will somehow suddenly find sagacious angels to run the system at that point? The real answer is market-based and comprehensive demand and supply side reforms of the kind I captured in a separate blog post.

Here is what I predict: HHS will view a few isolated reform proposals that might work in certain settings but not all, decide that it is something that should be centrally mandated and in fact applicable to all, follow that with the creation of a 900 page unreadable document that hospitals and clinics, in despair, are forced to hire a team of consultants to figure out, but which gets the actual needs of patients and consumer transparency on pricing and outcomes precisely wrong.

 

 

A brief history of how the American healthcare system became high cost and low performance

In two separate but connected articles posted on the Mises Institute website, Part 1 covering the pre-World War II construct of American healthcare and Part 2 covering the explosion in healthcare costs and our current system development post World War II, Dr. Michael Accad, a Cardiologist with an impressive resume and who has a tremendously insightful blog, provides a remarkable yet succinct overview of how we got to where we are today, which can be briefly described as a costly and underperforming health system.

In just a few minutes, the reader will witness the 100+ year descent into the 7th layer of hell that is our healthcare system and all the errors and paternalistic hubris that got us there. Begin with the status of healthcare in the 19th century, which while far from ideal (this is the era when bloodletting, blistering, and toxic purgatives were common, after all), was beginning to witness the emergence of competitive and innovative medical reforms under a scientific and competitive basis under the guide of the free market invisible hand. For example, germ theory and surgical advancements, and the formation of high-performing health systems such as Mayo Clinic that practiced care on these scientific foundations, were beginning to blossom in the late 19th century without the meddling hand of government agencies and regulations that are prevalent today. But then everything changed when in the early 1900s, a sensational report on the inadequacies of the health system penned by Abraham Flexner resulted in reforms in more onerous physician licensing and health education that remain largely intact to the modern-day. The offshoot was a tremendous narrowing of diversity in medical approaches and education models and medical practices. Everything outside of the Flexner dogma was ostracized and shunned. The challenge with this paternalistic approach is that licensing led to self-serving restrictions on the supply of physicians, leading to spiked costs.

Part 2 of the series covers the evolution of the American health system into what we know today. With increased costs came a decrease in demand. With excess hospital and physician capacity, leaders in healthcare began crafting strategies to increase collective payment models that would blunt the direct cost impact on consumers and thereby increase demand in line with existing capacity. While a European national health system seemed politically out of the question, pilot models in which employees of a Dallas school system were part of a collective payment system seemed to offer the best model to emulate more broadly in order to bring up hospital service demand as well as mitigate adverse selection of the sickest patients opting into insurance plans. Intuitively, people who are able to work are typically healthier than the average American. Legislation promoting insurance plans duly followed, with favorable reserve requirements for Blue Cross and Blue Shield Programs compared to other types of commercial insurance as well as tax exemptions for employers who offered health insurance coverage through the 1942 Stabilization Act. My own editorializing is that the reader should bear in mind that this legislation was a compounding error in the sense that it was meant to address a challenge with employers being able to compete for employees given pricing and wage controls that were persistent in that era. Allowing employers to de facto increase their wages by offering health plans was a backdoor sop allowing them to more effectively compete for labor. The unintended consequences that we are still living with today is that we are collectively highly dependent upon employers for health coverage, which has its own perverse effects of holding people hostage to jobs as well as decreasing our direct take-home pay. The more immediate impact of this in the mid-century was a rapid increase in medical utilization and price inflation. I wish a magic time machine would allow me to just go remove the insidious price and wage controls in the first place.

Dr. Accad focuses heavily on the paternalism of the system that drove us inexorably towards the vicious cycle conclusion that government must take an active role in providing insurance, at great risk and ignorance of the ensuing moral hazards of over-using healthcare services that such an approach entails, which further leads to a whack a mole approach of controlling costs. Better to have not created the holes and brought in the moles in the first place, but I digress. Through a Question and Answer method, Dr. Accad elaborates on two aspects of moral hazard and how this most important of economic concepts impact health care:

Q:  What are the two aspects of moral hazard?

A: The first one, which matches the negative connotation of the term, is the aspect imported from other insurance settings. For example, in the case of car insurance, the term moral hazard refers to the fact that someone with car insurance might drive less carefully than someone without coverage. In a way, that person may be “taking advantage” of the insurance company.

In health care, that aspect of moral hazard probably exists, but may not be very important. For example, it’s conceivable that people who have insurance are more likely to engage in more dangerous sports activity. But this kind of moral hazard can probably be accounted for by the insurer and be factored into the actuarial analysis to determine premium prices.

The other aspect of moral hazard stems from the fact that every single medical encounter or medical act can be said to be ordered toward the preservation of life or toward the well-being of the person. This by itself presents a strong incentive to use medical services, and the behavior should not have the same negative connotation as in the first aspect of moral hazard. In fact, economist John Nyman has argued that the behavior by which insured people would use more health care is a social good.

The bottom line is that one does not need to be sick to utilize medical services and that all that is needed is a plausible argument that if a medical action is taken, life may be prolonged or enhanced. Such plausible arguments are not hard to come by, especially in a health care system where doctors and hospitals are largely paid on a fee-for-service basis. There is no objective limit on what can be considered “desirable care,” and if cost is not a consideration, more medical actions will be taken.

Of course, when consumers are shielded from direct costs, there is little to stop inflation. Insurance premium inflation has consistently outpaced general inflation since the 1950s. Stop and think about how remarkable that factoid is. Dr. Accad addresses this as well, and I love the comparison of health insurance to a harmful drug:

Q: Didn’t the increasing cost of insurance hurt employers?

A: To the extent that it did, there was not much employers could do about it. With rising medical prices, the need to have health insurance would become more and more acute. Employee discontent would have been too great to abandon health insurance as a benefit. Executives themselves also benefited from the group rate, so the idea that health insurance should be abandoned could not be entertained seriously.

Q: People were hooked!

A: Health insurance is a seriously addictive and harmful social drug.

Once medical price inflation occurs for those who are covered, those who are not covered begin to get priced out of the market. During those times, it tended to be the poor, the aged, and unemployed who were left in the lurch, and that brings us to Medicare and Medicaid:

Q:  How was the situation addressed?

A: With the enactment of Medicare and Medicaid in 1965. The government provided generous health insurance benefits to the most politically influential class, the elderly, which also happens to be the class whose needs for medical care are naturally the highest.

The terms of Medicare insurance were also very generous to physicians and hospitals since, to secure their cooperation, the government decided to pay them their “usual and customary rate,” which means that, for a time, the government had no way of controlling costs.

Q: I can see things spiraling out of control…

A:  As a matter of fact, once Medicare was introduced, medical prices became completely “unhinged.” Within a few years, Medicare expenditures were quadruple what had been anticipated.

The demand for medical services was so high there was an acute shortage of doctors. Immigration laws were adjusted to allow a rapid influx of physicians from abroad. There was a boom in hospital construction. Incredible facilities and health care complexes were built.

Naturally, with skyrocketing medical prices, insurance premiums had to increase correspondingly. This began to really affect employers.

The rest of Dr. Accad’s journey through the American health system history concludes with the modern-day challenges to restrain the predictable cost increases that ensued with Medicare – from the Managed Care Organizations that were designed in the 1970s to the various pay for performance schemes, Accountable Care Organizations, and shifts from fee for service that we see today. Some of these are likely steps in the right direction, and it is certainly better to pay physicians based upon outcomes and quality rather than volume of services. That being said, with all of the recent mandates and focus on payments for an entire episode of care that has and will incent mergers and consolidation, I am not sure the incentives will truly be great for newly minted local monopolies to increase quality and pass on cost savings to consumers.

It would be far more effective to implement policies that end onerous licensing and task performance restrictions (i.e. by allowing nurses to perform tasks they are perfectly capable of), end supply side restrictions (it is near impossible to open a new hospital in an area due to hospital political lobbying and political connections at the local and state level), end reliance on insurance that covers everything, which obfuscates health care prices, provide individuals with the same tax advantages that employers receive for health service coverage, shift employer based coverage to portable and widely usable health savings accounts, and replace health insurance subsidization for the poor with directly funded health savings accounts similar those enjoyed by their better off peers. Such a model would drive greater innovation, better customer service, and more transparency around outcomes and costs. All of these combined would tame cost inflation while at the same time increasing health outcomes.

 

The Next Frontier in Healthcare Reform and Why it Will Harm Consumers

There is a working group chartered by Health and Human Services (HHS) comprised of a combination of private, public, and non-profit players in the healthcare industry that have been active in determining the direction of the next frontier in healthcare reform. Namely, the next frontier in healthcare reform will focus on how providers and organizations are paid for the services that they deliver. This working group has been given that rather lengthy title of, “The Health Care Payment Learning & Action Network (LAN),” and they recently created a whitepaper that sheds tremendous light light on the Centers for Medicare and Medicaid Services (CMS) most likely direction and next steps with looming payment reforms. The whitepaper can be found at https://hcp-lan.org/workproducts/apm-whitepaper.pdf. At the outset I will say that I am a tremendous skeptic of this type of crony capitalism in which entrenched monopolistic industry players such as large hospital networks and insurance companies that have close connections with government are the ones that are creating frameworks for payment models. We won’t be surprised when such models are favorable to them at the expense of consumers and the small-market players, would-be new entrants, and competitive market forces that are so sorely needed in healthcare.  That is a topic I will leave to a future post and in many ways I discussed in my healthcare section of  a recent blog post where healthcare is one section addressed within a broader economics manifesto in which I borrow liberally from University of Chicago Economist John Cochrane.  Suffice it to say that asking the fox for the right ways to guard a henhouse are likely to result in a more well-fed fox then it will result in protected hens.  Let me also say at the outset that I am not an advocate of the largely fee-for-service regime that exists in healthcare today. I will briefly indicate that I do not believe government “expert” led attempts to change healthcare demand and supply through insanely complicated bundled payments for episodes of care will be the new tweak that bends down our healthcare cost curve while protecting quality and consumer choice. The new reforms are analogous in my mind to building a pretty white picket fence on a trash heap. Broad market-oriented reforms are the real cure, the effective way to remove the trash heap and create meaningful healthcare reform, but again, that is a future post.

Now turning to the merits of the plans put forth by the HCPLAN. What good is a government body if it does not have a 6 letter acronym?  The graphic below reveals how they group categories of Alternative Payment Models being advocated.

Payment Reform

It is clear that the working group (and one can assume they will guide in large part the decisions that CMS will make) holds in high regard the bundled payment for a specific episode (i.e. hip and knee replacement) and a population based payment (payment that is for a beneficiary as a whole and agnostic to the services they actually wind up using) as the holy grail models of payment reform. It is also interesting to note the convergence of government and private payer focus on such payment reform models (my point above on crony capitalism at work). Thus, this is not simply a government thrust, but is being directed by the large industry players that will benefit from more complicated payment structures that only large providers will have the scale to work around  The working group makes their strategy clear with statements in the white paper such as, “The Work Group believes that shifting from traditional fee for service (FFS) payments to person focused payments (in which all or much of a person’s overall care or care for related conditions is encompassed within a single payment) is a particularly promising approach to creating and sustaining delivery systems that value quality, cost effectiveness, and patient engagement.” Thus, healthcare systems can anticipate that what CMS has begun with bundled payment pilots and the recent Comprehensive Care for Joint Replacement Model (CCJR or CJR) is but a mere crack in the opening of the door that will highly likely culminate in many other healthcare conditions being moved into a bundled payment models. Indeed, in the work group whitepaper, the call is for health payments to increasingly shift towards Category 3 and 4 payments. This will intuitively fuel consolidation across the acute and outpatient settings as well as drive a much more narrow and controlled continuum of care networks. In other words, as healthcare consumers, we will be left with much fewer options and much less control over where and how we consume healthcare services.  In this era of payment structures, hospitals will have great incentives to create unprecedented levels of of hospital-based control (if not outright ownership) over outpatient and post-acute settings through tightly controlled referral agreements and at risk quality and financial contracts between hospitals and outpatient settings. The outpatient settings that can’t keep up in this space will inevitably be shutting their doors.Many hospitals will find it to their advantage to simply acquire the outpatient and post-acute players around them. Indeed, to their credit the working group admits in their whitepaper that, “The transition away from FFS may be costly and administratively difficult….the Work Group recognizes the possibility that shifts in payment can result in unintended and unanticipated consequences, such as cost increases owing to provider consolidation, reduced provider willingness to exchange data, and a potential reduction in costly but effective medical services”

On the points made related to the unintended consequences, something to watch out for will be how CMS plans to address the natural incentives that bundled payments will create to reduce innovation and quality of care in order to cut costs. It won’t come as any surprise that a bundled payment will fuel cost reduction at the expense of quality and consumer value.  I personally am skeptical that government apparatchiks will be able to command these tradeoffs from up on high effectively.  Since the ultimate aim in any industry should be to both reduce cost and increase value in order to please and gain more customers, a bundled payment by its inherent nature will greatly incentivize lower cost care that does not in fact improve quality, or even worse, will highly likely decrease quality. Thus, there will have to be some efforts to couple the bundled payment to pay for quality reforms. All that being said, health systems and consumers can anticipate government reform to continuously work towards the rapid shift from fee for service to at least one of the APM payment frameworks despite the recognized challenges. After all, recognized challenges did not stop the Obama administration from rolling out disastrous insurance exchanges.

The graphic below reveals a rough representation of the shift that the Work Group believes must occur. While the precise amount that flows into Categories 2-4 can’t be predicted at this juncture, what seems a foregone conclusion is the shift out of Category 1 (Fee-For-Service) is all but inevitable in today’s current environment. Those organizations that do not opt for full on Accountable Care Organization models created under ObamaCare will increasingly find the majority of their payments in the form of person-centric population bundled payments, episode of care bundled payments, or payments for services in which a significant portion of the payment is dependent upon achieving certain quality measures.

 

Model Shift

In its discourse on the payment models, the Work Group unveils its construct of the holy grail of health care delivery: the integrated care delivery network. It states within the white paper that, “On one end of the spectrum, plans and providers in Category 4B models may be virtually integrated. On the other end of the spectrum are highly integrated arrangements that are characterized by vertical integration of financing and care delivery, common ownership, and strong linkage across strategy, clinical performance, quality, and resource use. These groups may also have a higher percentage of salaried physicians. After reviewing the literature and discussing these highly integrated arrangements with people who operate within them, the Work Group has reached the conclusion that they can be ideally suited for delivering person centered care because they: 1) force transformational thinking about delivery system reform; 2) optimize coordination of infrastructure investments; 3) most fully remove financial incentives for volume; and 4) expedite community investment and engagement.”

There you have it – a frank admission that these payment models will drive consolidation of health systems, drive small players out of the market, and drive private physicians into the arms of working directly for hospitals. I personally believe that a competitive market without the insane supply restrictions and prevention of new entrants of the market and removing of the insurance premiums and government programs that create tremendous price and demand distortions would create the cost and quality driven models we seek, but what we are getting instead will be more complexity, less choice, and potentially less quality. With some luck, maybe our costs will go down, but I am not betting on the benevolence of even larger industry monopolies passing their cost savings on to consumers.