CURED!
The Insider’s Handbook for Health Care Reform
Stephen S. S. Hyde
© 2009 Stephen S. S. Hyde.
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First printing 2009
ISBN:978-0-9840556-0-9 (hardcover)
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LCCN:2009928297
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To Loren, Evan, and Erin
CONTENTS
Introduction
The Upside-Down Economics and Persistent Myths of American Health Care
Part I—THE PROBLEM
CHAPTER 1
The Fundamental Problem with American Health Care and a Proposal to Remedy It Market Failure
Why the Market Failure Persists
The Goals of Health Reform
The American Choice Health Plan
Chapter 2
Health Care Delivery: The Key Problems and Issues
The Cost and Affordability Problem
How Much Should We Spend?
The Quality Problem
How Scientific Is Modern Medicine?
The Chronic Disease Problem
The Prevention Problem
Doctors and Prevention
Public Health
The Fallacy of Lifetime Medical Costs
Who Benefits from Cost-Benefit?
The Free-Rider Problem
Chapter 3
Consumer Roles and Rights
The Role of Consumers
Online Consumer Information
Medical Travel
Retail Generic Drugs
The OTC Drug Market
Non-Traditional Medicine and Dietary Supplements
Lasik Eye Surgery
Gastric Banding
Retail Store Medical Clinics
The Medically Savvy Amish
Hyde Rx Services Corporation
Consumer-Driven Health Plans
Federal Employee Health Benefits Program (FEHBP)
The Medicare Drug Program
Is Health Care a Right?
Chapter 4
Health Insurance: What’s Wrong with It and What Needs to Be Done About It?
The Uninsured Problem
The State-Mandated Uninsured
Goals
Why and How Has Health Insurance Failed to Meet These Goals?
A Troubling Conclusion—Market Failure
Premium Rate Setting
Why Not Mandate Health Insurance?
Part II—GOVERNMENT ATTEMPTS TO FIX THE PROBLEM
Chapter 5
Medicare, Medicaid, and SCHIP
Medicare
Medicaid and SCHIP
Chapter 6
HMOs, ERISA, and CDHC
The HMO Act
ERISA
MSAs, HRAs, and HSAs
Chapter 7
The Quieter Complications
Tax Policy
State Medical Practice Laws
State Minimum Insurance Benefit Laws
State High-Risk Pools, Guaranteed-Issue, and Insurance Reform
“Any-Willing-Provider” and “Freedom of Choice” Laws
“Corporate Practice of Medicine” Prohibitions
COBRA
HIPAA
Specialty Hospital Limitations
EMTALA Patient Anti-Dumping Statute
Part III—THE CURE
Chapter 8
Why Not Single Payer?
A Government-Mandated Benefit Plan
Administrative Efficiency
Single Payer in Other Countries
Single Payer Is Not Necessary
Chapter 9
The American Choice Health Plan
Fundamental, Comprehensive Reform
American Choice Regulatory Reform and the Role of Government
Tax Reform and HFA Funding
Insurance Reform
Chapter 10
Free Rider Prevention and Insurance Company Regulation
Access and Adverse Selection
Reform of Minimum Benefits Requirements
Setting CCC Limits
Regulating Insurer Participation
A Uniform Benefit Plan for All?
A Challenge to Insurers
Chapter 11
Premium Reform
“B” Is for Behavior
Chapter 12
Toward Universal Participation, Provider Reforms, and Lower Costs
Medicaid and SCHIP Reform
Medicaid and Late Enrollment Penalties
Funding the Safety Net
Provider Reform
Ending the Monopoly of the Medical Cottage Industry
Price Transparency
Coordination and Electronic Medical Records (EMR)
Provider Competition
The Cost of Insurance and Medical Care under American Choice
Conclusion
A Future Scenario and Major Savings
The Savings
Appendix
Who Wants to Be a Trillionaire?
Introducing Iris Wilde and CompreNet
Excerpts from CompreNet’s Business Plan
Epilogue
About the Author
Acknowledgments
Notes
Index
Introduction
The Upside-Down Economics and Persistent Myths of American Health Care
The American health care system is a disaster. The purpose of this book is to describe how it came to be this way and to offer a way out. The punch line of this book is a deceptively simple proposition. We can resolve virtually all the problems of our massively dysfunctional health care system if we can figure out how to get America’s consumers to demand and to act on the answers to two questions:
1.For my medical needs and personal circumstances, which health care providers, procedures, services, and products offer me the highest quality, most beneficial outcomes?
2.Of those high-quality treatment options, which ones cost the least?
Let me ask you to suspend any disbelief that consumers ever can, will, or even should ask these questions or act on the answers. The arguments that they can’t, won’t, or shouldn’t are bogus. That’s lesson number one from my nearly forty years of toiling in the fields of health care regulation and management.
If the two questions above seem somehow familiar, it’s because they focus on the basic value proposition that all American consumers ask every day of their lives for virtually everything they buy—food, clothing, housing, transportation, recreation—everything, that is, except health care.
The problem lies in the failure of consumer markets to evolve in health care the way they have in other aspects of our lives. At the heart of this failure is a fundamental difference that separates health care from our other wants and needs—but it’s probably not the one you think. It is this: Although high prices almost always connote optional luxury goods and services, they don’t with health care. A quarter-million-dollar liver transplant can be just as necessary as a two-cent aspirin. There is nothing luxurious about it. Thus, for everyone to have the ability to consume the full range of necessary medical care, they must have insurance to pay for the expensive stuff. The primary market failure in health care is that markets have not emerged to offer such insurance to everyone. This is the crux of our problem.
We have failed to recognize and fix this market failure largely because its existence has been obscured by uncounted layers of myth and practice that almost all of us have accepted as the way things must be. Almost utterly ignored, or even rejected, is the reality that medical care is what economists refer to as an economic good that is subject to the dynamics of price-mediated supply and demand. It is not, as many believe, a public good or a basic human right. I wish it were. Because of this market failure, we now suffer under a system that would be more familiar to Lewis Carroll than Adam Smith.
We spend more and more money while excluding more and more people from care. Only in health care does excess supply create its own excess demand with no decrease in price. This phenomenon even has a name in economics—the Roemer Effect. Therefore, to lower costs, we have tried to restrict the supply of health care facilities and providers—a futile effort in defiance of basic economics.
Increasingly, the more innovative new providers (such as specialty hospitals) are, the more state and federal governments have suppressed them because of the threat they represent to existing, far less efficient players. And if competition is considered bad in health care, price competition is especially bad. Maybe that’s why we let the federal government control prices on virtually all doctor and hospital services. Then, in an effective coup de grâce to any sort of microeconomic market solution, we have hidden even these artificial prices from consumers, lest they foolishly use them as a guide to actual value.
We face a dire shortage of primary care doctors, yet the government continues to set their reimbursement rates at the lowest levels, with insurers going along as willing co-conspirators. At the same time we legislatively restrict highly qualified nurse practitioners from practicing to the full extent of their well-documented capabilities.
Often, low-cost generic drug competition causes sales of a brand-name medication to suddenly drop by 97 percent. So does the maker of the brand-name drug drop the price to compete more effectively? No, because the perverse rules of health care economics dictate that the rational approach is actually to raise the price. The same drug companies sell their most expensive drugs to you for not one price but two: an extremely high one if you have insurance and free if you don’t, thus providing perverse incentives for some sick people to actually drop their insurance coverage.
Why do we empower people to smoke, eat, and drink themselves to death by requiring those with healthy lifestyles to subsidize their self-destructive behaviors? And why are we increasingly making doctors accountable for preventing the diseases that predictably result from their patients’ 24/7 lifestyles?
As medical costs rise, we force insurers to cover even more unnecessary services, thus driving insurance premiums even higher. We require insurers to cover normal consumer purchases, no matter how cheap—even though this adds overhead, profit, and parasitic billing and reimbursement expenses that can double the cost—while completely hiding prices from consumers.
We justify all this on the basis that people supposedly value and use only the health care they think they’re getting for free, even when it drives insurance premiums beyond anything many of them can afford. Even worse, people without insurance, who can nonetheless pay their doctors upfront, are required to pay the highest prices while bureaucratic insurers that delay payments get to pay less than half as much. And many uninsured consumers who could pay—but simply refuse—often escape paying anything. This leaves the hospitals and doctors to pass these costs on to those with health insurance, thus further driving up their premiums.
Every day ordinary consumers buy and integrate complex choices of computers, automobiles, software, and communications technologies into their lives. But they can’t be trusted to make their own choices about medical care. Instead, we let others—the government, employers, insurers, and doctors—tell them what medical care they can have and which providers they can use. Then consumers are told how much they have to pay for it all. If we had a similar system for buying cars, we’d have a revolt on our hands. Because none of this has worked well, many health reform advocates now propose to let the government force everyone to buy what they supposedly need—a uniform set of health insurance benefits that takes no account of individual needs, circumstances, means, or preferences.
Even though advertising is generally viewed as an essential, informative—if frequently annoying—component of our consumer economy, prescription drug advertising is increasingly castigated as harmful and in need of prohibition, as it is in Europe. In our everyday lives technological advances make virtually everything better and cheaper—except health care, where technology is blamed for driving costs higher. Maybe this helps explain why doctors have resisted electronic medical records, thus leaving health care as our sole remaining paper-documented industry.
We have witnessed no improvements in the office productivity of many doctors over the past forty years, yet the states persist with restrictive corporate-practice-of-medicine laws that prevent medical practices from adopting organizational, ownership, and management forms that have transformed the rest of American industry from the 1800s to this day.
Our private health insurance system is employer-based. That means people too sick to work can’t get coverage. Small business is the great economic driver of the American economy. Yet we saddle it with excessive health care costs, regulations, and mandates while we exempt large employers. Then the big companies squander their privilege by hiring pharmacy benefit managers who make their employees pay higher prices than they could have gotten on their own with a modicum of savvy retail shopping.
This system is so upside down that workers actually complain when expensive prescription drugs become available over the counter at 70 percent lower prices. Why? Because they now have to pay more for them. What on earth is going on here, and why do so many of us accept this situation as normal?
Many reform proponents argue that richer people should pay more for their health insurance than poorer people. Yet they simultaneously support employer-based insurance that requires younger, lower-paid employees to subsidize their older, richer colleagues—or drop their own insurance altogether. When many young workers quite rationally do the latter, the reformers then blame them for supposedly believing they’re invincible. These same reform advocates would fix the situation with the simple expedient of making it illegal not to buy health insurance—despite the fact that no one has ever been required to purchase anything as a condition of living in America—and that includes car insurance.
Everywhere else in our economy, profits are a sign of customer acceptance, efficient operations, and good management. In health care, they are seen by many pundits as evidence of rapacity, wasted resources, and denied care. Drug companies, whose products prevent disease, heal the sick, and reduce medical costs, are demonized as conniving price gougers because they rationally follow the rules of an irrational game not of their invention—not that they’ve done much to try to change such a lucrative game. Health insurers that keep their members out of bankruptcy are said to be the greedy, heartless bad guys who are in cahoots with an all-consuming black hole of medical providers, yet reformers would have us believe we’re supposed to force everyone to buy from them anyway?
We celebrate when medical costs increase at only twice the prevailing inflation rate. Providers who harm patients are paid more than those who heal them. And if anyone tries to exclude sub-par doctors, we pass laws to require that they be treated and paid equally with the best ones. We claim to have “the best health care system in the world,” even though your chance of being treated according to current medical standards is the same as getting heads on a coin toss. Doctors deride these professional standards as “cookbook medicine” that any well-trained nurse practitioner with a computer could achieve.
Many pundits support more federal debt and unfunded mandates to pay for more health care spending. Yet many of the same critics discourage consumer savings and investment that could support better individual health choices.
In this upended universe, we hear calls for yet more government control to improve, of all things, private sector efficiency. Better yet, say others, we should force business out of health care altogether and let the government run it all more responsively, compassionately, and cost-effectively—presumably as the government has done with banking and securities regulation, mortgage lending, the Congress, military weapons procurement, the FAA, the FDA, and the IRS. True, increased government control hasn’t worked so far, but surely more of it will. Top-down, rules-based control is all the rage. Market capitalism has become the new pariah of health care.
Widespread acceptance of such inverted economic thinking by people who should know better has deeply affected public perceptions of health care’s problems and how we should go about solving them. It has led to numerous beliefs that simply don’t hold up to rational scrutiny. It is as if the ruling mantra in health care is “We hold these myths to be self-evident.” And the myths come in all sizes and flavors. Here are some of the big ones:
·- Insurance coverage for primary and preventive care saves money by preventing expensive diseases.
- Such insurance coverage is necessary because people won’t buy preventive services on their own.
·- Electronic medical records will reduce total health care spending.
·- There are forty-six million Americans who can’t find or can’t afford health insurance.
·- The uninsured are the biggest problem in health care. Solving it will lower total health care spending.
·- Our health care system produces the worst life expectancy and infant mortality statistics in the developed world.
·- Requiring everyone to buy health insurance is the only way to deal with free riders and to solve the problem of the uninsured.
·- So many young people have no insurance because they think they’re immortal and don’t need it.
·- Getting the uninsured youngsters to buy insurance will help pay the growing health care costs of the aging boomers.
·- Insurance company profits are a big contributor to excessive health care costs.
·- Letting Medicare negotiate drug prices will solve the problem of excessive pricing by Big Pharma.
·- Uninsured people who use hospital emergency rooms are a big cause of cost-shifting to the rest of us.
·- A large percentage of all health care spending occurs during the last year of patients’ lives.
·- We may spend a lot more for health care than other countries, but at least we have “the best health care system in the world.”
·- A national health board that sets medical practice standards will improve quality and lower costs.
·- Paying more money to doctors who do the right thing will improve quality.
·- Doctors have a natural, rightful monopoly on the practice of medicine.
·- Health care is a public good.
·- All licensed doctors are created equal and must be treated that way. (Question: What do you call a medical student who squeaks through graduation at the bottom of his class? Answer: Doctor.)
·- Doctors are the key factor in preventing chronic diseases.
·- Specialty hospitals unfairly harm community hospitals.
·- Medicare, with its low administrative costs, is more efficient than private insurers.
·- The free market can solve all our problems in health care.
·- A consumer market-based system can never work because medical care is too technical and too complex for consumers ever to be able to navigate and purchase on their own.
·- Employer-based health insurance is dominant because of a World War II tax ruling that excluded employees’ health benefits from their income taxes.
·- The dominance and success of employer-based health insurance makes it worth preserving and strengthening.
·- Requiring employers to cover health insurance will improve workers’ living standards.
·- The lack of insurer motivation to promote long-term prevention is the result of frequent membership turnover.
·- Community rating, in which everyone pays the same health insurance premium, is the fairest pricing method.
·- Individual insurance is inherently inferior to employer-based group insurance.
·- Consumer-driven health care and health savings accounts (HSAs) don’t and won’t work because consumers can’t get good information on health care prices and quality.
·- Consumer-driven health care is just another way of saying “the patient pays more” and is especially unfair to the poor and to people with chronic diseases.
·- Health care quality and cost will improve if government, employers, providers, and insurers coordinate to focus on the patients.
In this book I will establish that each of these assumptions and assertions is either merely wrong or dead wrong—and that any attempt at serious reform founded on any combination of such beliefs is doomed.
Why do people believe these myths if they’re not true? Liberal economist and Nobel laureate Paul Krugman’s coinage of the “anti-Cassandra effect” may help explain it—if somewhat cynically. Cassandra was the beautiful young daughter of King Priam of Troy in Homer’s Iliad. She was blessed by Apollo with the gift of prophecy but also cursed never to be believed by anyone. Krugman’s anti-Cassandra effect holds that there are those “who have been wrong about everything—but are still, mysteriously, treated as men of wisdom”—an especially ironic bon mot, considering Krugman’s own position favoring single-payer health insurance reform.(1)
Market economist Thomas Sowell takes a more analytical approach, pointing out that “fallacies are not simply crazy ideas. They are usually both plausible and logical—but with something missing. Their plausibility gains them political support. Only after that political support is strong enough to cause fallacious ideas to become government policies and programs are the missing or ignored factors likely to lead to ‘unintended consequences,’ a phrase often heard in the wake of economic or social policy disasters.”(2)
Whether you prefer liberal Krugman’s or conservative Sowell’s explanation, each economist pretty well sums up the conventional state of health care—past and present. There is too much conventional thinking and too little objective scrutiny of its dynamics, defects, and potential solutions. It’s a lot like Samuel Johnson’s reference to second marriages as triumphs of hope over experience.
I propose we move to the fifty-thousand-foot level and look at the medical landscape as just another essential component of our national consumer economy but one that also presents a uniquely problematic market and regulatory failure. Such a perspective can suggest solutions that have thus far eluded those who see health care as something operating under a different set of economic principles. It doesn’t. The failure of the public and private sectors (and more than a few economists) to recognize this is at the root of virtually all the problems we now see in inadequate insurance, poor care quality, high costs, and a looming pandemic of preventable diseases. A more realistic view of health care can lead us to a uniquely American solution producing dramatically better quality, lower costs, and universal access to affordable health insurance.
From such an Olympian perch, it becomes apparent that the consumer markets reliably supplying us with high-quality affordable food, clothing, housing, and transportation just might be able to do the same thing with medical care. Let us take advantage of this view to seek clues for crafting a more effective bottom-up, appropriately regulated, consumer market-based approach that will replace the top-down, rules-based system that governs it now.
If we’re going to address our needs in reforming health care, we must agree on two inconvenient truths. First, employers’ and government’s historic roles in health care have failed to deliver. Continuing or increasing those roles will only exacerbate and accelerate that failure. Second, unfettered market forces alone will never spontaneously create a market that will allow everyone to gain needed access to expensive medical care. Fixing health care will require a regulatory approach that renders unto government that which is rightly government’s, and to markets that which is rightly markets’. It is my intent to show how we can do this and to resolve virtually all of the major problems in our health care financing and delivery system.
As for the myths, I used to believe a lot of them myself. If at times I appear preachy, please grant me the slack you would a former smoker who now proselytizes his newfound vision of abstinence. We mean well. And we have a valid point. We just need to be less pushy and more humble.
Part I—THE PROBLEM
This book is organized into three parts. Part I is primarily focused on laying out and analyzing the problems of our unstable, unsustainable health care financing and delivery system—and especially why it has developed the way it has. The first chapter provides an outline of my proposed cure: The American Choice Health Plan. Part II covers past steps and missteps by the government to fill in the gaps presented by the market’s failure to provide affordable health insurance to everyone who wants and needs it. Part III provides a look at two diametrically opposed cures for our sick system, the first a single-payer system and the second my prescription for The American Choice Health plan.
Chapter 1
The Fundamental Problem with American Health Care and a Proposal to Remedy It
The thesis of this book is simple. Our current health care mess is the result of a largely unrecognized but correctable market failure. This failure has prevented a viable consumer market from emerging to efficiently deliver the necessary, high-quality, and affordable medical care we all need. What we have instead is a balkanized system of private and government programs that lack a comprehensive focus on meeting the medical needs of America’s consumers in an economically sustainable fashion.
Virtually all current proposals for health reform suffer from major—usually fatal—flaws that fail to address this market failure. Fixing the system will require what many will consider a radical approach, a fundamental realignment of the relationships among government, employers, insurers, health care providers, and consumers, effected in the following ways:
- Government: First, government must establish and enforce a regulatory environment in which comprehensive consumer health insurance and medical care markets can function; and second, government must provide financial and social safety nets for those who lack the ability to participate in these newly empowered markets. Among other things, this means getting government out of the health insurance business.
- Employers: We must change employers’ role from providing their employees with little or no choice in health benefits to one of providing them the funds to purchase their own coverage from a plethora of private insurance offerings.
- Insurers: The insurers’ role must revert to the fundamental function of providing financial protection against the unaffordable costs of medical care while becoming directly responsible to the people they insure rather than to government, employers, and providers
.
- Providers: Each health care provider must become directly accountable to its consumers and patients rather than to government, insurers, and employers.
- Consumers: To gain the clout to demand all this accountability, consumers must control all the money for their own health insurance and medical care.
Once again, the effectiveness standard of such a regulated market solution would be the extent to which America’s consumers demand and act on the answers to the two questions I raised in the introduction:
1.For my medical needs and personal circumstances, which health care providers, procedures, services, and products offer me the highest quality, most beneficial outcomes?
2.Of those high-quality treatment options, which ones are the least expensive?
Giving consumers the authority and responsibility to purchase their own health insurance and health services may sound deceptively simple, but doing so will correct virtually all of the current system’s shortcomings. It will fix the inadequate access to health insurance, lack of affordability, inconsistent quality, under-funded government programs, and health care provider shortages. We are clearly a long way from such a solution now.
America is a market capitalist society in which the voluntary behavior of millions of buyers, interacting with millions of sellers, allocates limited economic resources to satisfy individual wants and needs. Despite manifold attempts to develop better systems over the centuries, none has ever topped market capitalism’s status as the most effective known approach for creating and distributing economic wealth. Yet market capitalism has utterly failed to deliver an efficient and effective health care system, despite the fact that medical care is a scarce economic good that is subject to the same supply-and-demand dynamics as our other essential needs in life.
Why is that? Some claim it’s a problem of excess profiteering by insurers, health care CEOs, and drug companies and thus too much rampant capitalism. Others see the culprit as too much government regulation and intervention and therefore too little market capitalism. Neither explanation properly characterizes the real issue, nor does it form the basis for a comprehensive solution. The real problem lies in a fundamental market failure that neither private nor public remedies have recognized or corrected.
Market Failure
The market failure is that—unlike in the cases of our other basic necessities of life—no naturally arising market mechanism will allow everyone to obtain the health insurance required to afford the full range of necessary medical treatments for expensive, life-threatening maladies. Let me explain.
There are essentially five fundamental human needs necessary to survive in modern society: food, clothing, housing, transportation, and medical care. (We might also include education, but that discussion is well beyond the scope of this book.) In our country we obtain the first four efficiently and affordably via essentially self-organizing markets operating under the rule of law—i.e., regulation. In meeting such needs, we find in each category a vast range of prices for different goods and services. In almost every case the high-priced products and services constitute luxuries that may add to our enjoyment of life but are hardly necessary. The basic necessities, on the other hand, are always cheaper and are affordable for almost everyone in any advanced economy like ours. Chicken is as nourishing as lobster, and clothes from Wal-Mart will keep a person as warm as those from Saks Fifth Avenue.
Health care is different. Expensive medical services are just as necessary as the inexpensive ones. With non-relevant exceptions, such as some elective procedures, they are rarely a luxury. Thus, while with food, clothing, shelter, and transportation we can distinguish between necessary and luxury goods on the basis of low and high prices, with medical care we cannot (see graph below). It is unique among life’s necessities in not having a significant luxury component that correlates with price. If you need a liver transplant, no one would consider it a luxury in the commonly accepted sense of the word. None of my classmates at Harvard Business School ever told me they wanted to make a lot of money so they could enjoy a heart transplant when they got older, even though it’s something few people can afford on their own.
However expensive such medical services might be, few people feel they should have to forgo them in a prosperous economy. We tend to see them as unwelcome necessities foisted on us without regard to wealth or class, either as a result of bad luck or, increasingly, the long-term effects of bad behavior. Either way, access to them is not something most of us are willing to yield to the rich.
Because the need for expensive medical care strikes unpredictably and affects only a minority of the population at any given time, we have the fortunate opportunity to make it broadly affordable with insurance. By pooling financial resources from many individuals, we can pay the costs of those few who draw a losing number in life’s medical sweepstakes. Economic history shows that insurance markets have spontaneously emerged to protect policyholders against financial losses in such diverse areas as ocean shipping, home ownership, personal disability, death, automobile accidents, credit defaults, beautiful legs, and many others.
Insurance markets allow a person to pay an affordable premium to an insurer that agrees to indemnify him against losses defined by the insurance contract. Insurance specialists, called actuaries, estimate the risks and costs and then set the premiums accordingly. Other specialists, called underwriters, make sure that each prospective client represents an acceptable risk that will not endanger the actuarial soundness of the overall risk pool.
This underwriting function is the point at which market failure in health insurance rears its nasty head because of the phenomenon of “adverse selection.” If an insurer were to allow consumers the opportunity to buy insurance whenever they wanted it—as they can do in purchasing their other necessities—no rational person would do so until the benefits she would receive would equal or exceed the premiums she had to pay. Healthy people would wait until they were sick to buy health insurance, thus “adversely selecting” themselves into the insurance pool. Such a system can never be financially sustainable because the pool will always lack the necessary funds from the healthy majority to pay for the costs of the sick minority. No insurer would ever voluntarily enter such a market because—absent subsidy—it would inevitably go broke. A fire insurance company would not long survive if it sold home insurance to those whose houses were already on fire.
In health insurance, markets have dealt with the phenomenon of adverse selection via two market-generated mechanisms: employer-based group insurance and medically underwritten individual insurance. Therein lies the market failure. These insurance markets, by rationally protecting themselves from adverse selection, must systematically exclude large numbers of people altogether from buying their products—including the unemployed, the sick, the poor, the disabled, and the elderly. Over the decades this practice has led to increased governmental attempts to fill in these structural gaps with programs such as Medicare, Medicaid, and SCHIP.
Still, major gaps remain, with the result that—according to my calculations—fully fifteen million people are now excluded from affordable health insurance coverage in this country. That means fifteen million Americans are foreclosed from access to the full range of one of life’s basic necessities. (Note: Fifteen million is only one-third of the frequently quoted number of forty-six million Americans who lack health insurance, a subject I will delve into later.) The market failure results from the fact that there is no known naturally arising market mechanism that will allow everyone to buy the insurance necessary to access the full range of medical treatments.
So we need to figure out how—via regulatory or other means—to correct this market failure and the adverse selection problem that causes it. We must allow everyone to purchase affordable, necessary health insurance. If we can do that, then insurance markets will no longer exclude anyone from coverage, allowing everyone the ability to afford a full range of necessary health services when and if they need them.
The health care market failure problem could have been identified and remedied by government regulatory action at any time within the past seven or eight decades, but that never happened. It’s too bad, because relatively simple regulation could have obviated virtually all the problems we’re now experiencing in our medical care financing and delivery system. Instead, what emerged was an employer-dominated insurance system, later augmented by numerous government interventions. As a result, consumers were effectively removed from any significant say about from whom they can buy insurance, what it will cover, how much they have to pay for it, which medical providers they can use, and whether they can keep their insurance when they lose their jobs or government support.
Equally dysfunctional is the substitution of corporate and government bureaucracy for the flexible, dynamic solutions that well-regulated markets are capable of producing automatically and far more effectively. As a result, the individuals who actually consume the medical services have lost the financial clout to demand the quantity, quality, and affordability they regularly expect when purchasing other necessities. This elimination of the normal consumer’s role in medical care has been so thoroughgoing for so long that virtually everyone now sees it as the normal state of affairs. In fact, it is anomalous in the extreme when viewed in the context of the rest of our consumer economy.
Why the Market Failure Persists
Why hasn’t this market failure been corrected so that we can all simply purchase medical services ourselves, along with the health insurance we need to protect ourselves from catastrophes? I suggest the reason lies in our common beliefs and fears. Here are five of them, which I discuss below:
1.We have faith in government solutions.
2.Medicine is different from our other basic needs.
3.We fear and distrust markets.
4.Don’t we already have a market-based health care system?
5.Medical care is a public good, not an economic good.
Faith in Government Solutions
Health insurance came of age during the same period that Keynesian economics became popular in national economic circles. The Great Depression, along with heavily doctored evidence that the Soviet Union’s collectivist economic model was as effective as market capitalism, shattered much of the American belief in the effectiveness of markets—what economists would call microeconomic solutions. The new conviction was that only top-down government action at what economists call the macroeconomic level could prevent destitution and “put a chicken in every pot.” This belief was given further support during World War II, when the government took direct control over vast swaths of our industrial economy while heavily regulating the rest. The fact that we won the war gave even more credence to government’s ability to manage our economy better than leaving it to the unplanned, chaotic whim of markets.
The government’s focus on health care has tended to be directly interventionist in dealing with specific problems caused by market failure, which is reflected in the plethora of narrowly-targeted programs I describe in part II. The emphasis has not been on creating conditions to allow consumer insurance and medical care markets to function within reasonable regulatory confines. Of the numerous ad hoc attempts by employers and by federal and state governments to fix the problems caused by market failure, virtually all of them—though certainly benefiting particular interest groups—have made the overall system less effective, more expensive, and less sustainable.
So, instead of enabling a regulated health care market, our federal and state governments have cobbled together an increasingly inefficient bureaucratic patchwork of programs. These programs substitute for many of the functions that a market would perform automatically and far more responsively to the needs of its consumers. Employers, with their own bureaucratic management of group health insurance, have done no better.
There are many examples of distortional government interventions in health care—IRS policy, Medicare, Medicaid, the Hill-Burton Act, certificate of need laws, medical practice acts, minimum benefit requirements, the HMO Act, SCHIP, state high-risk pools, guaranteed-issue requirements, any-willing-provider laws, corporate-practice-of-medicine prohibitions, COBRA, HIPAA, specialty hospital limitations, and many others. All are attempts to fix specific problems caused, one way or another, by market failure, and each has created unintended negative consequences that properly regulated markets could have prevented.
One of the most inadvertently destructive government actions has been the price regulation that has virtually eliminated the information and incentives that could have allowed providers and consumers to come together in the delivery of low-cost, effective medical care. A federal agency called CMS (Centers for Medicare and Medicaid Services) has for years quietly regulated, either directly or indirectly, the price for virtually every medical product and service in the United States, whether Medicare-related or not. So far, only prescription drugs have been excluded. Because doctors and hospitals are required to bill Medicare and Medicaid according to CMS rules, insurance companies have been forced to follow suit and base their own reimbursement systems on the CMS structure. It has become virtually impossible, even illegal, for doctors to charge their patients on any basis other than CMS’s impossibly complex and arbitrary pricing system. Without clear prices, voluntarily arrived at between buyers and sellers, no market can exist for health care or anything else.
State and federal governments, by requiring insurers to cover even the most inexpensive consumer medical services, have further wrought havoc by misunderstanding the very principles of insurance. Not only does this result in hiding prices from consumers, but it also completely blurs the distinction between paying for normal consumer purchases and needing insurance as an instrument of protection only from unpredicted, unaffordable costs.
It’s as though your car insurance also paid for oil changes and gasoline. You can telephone your local Lube Stop to find out exactly the price they’ll charge for an oil change. But if you ask your doctor the price of a professional visit—not the copayment but the actual price the doctor is willing to accept for her services—she’ll shrug and maybe send you to accounting. There, one of the myriad billing clerks will look at you as if you just arrived from Mars. If you persist, someone may dig out a fee schedule but then tell you it’s irrelevant. Although the doctor will bill that amount to your insurer or other third-party payer, the doctor will almost always end up taking a much lower amount—based on what the government’s Medicare agency says it is worth.
To learn the actual price, you’ll first have to be seen by the doctor, then wait while she bills your insurance company or government program, then wait some more until she finds out how much it will pay, and then you may or may not finally receive a statement from the insurer telling you the allowable, negotiated rate owed to the doctor. Even then, it would not be the same price paid by another insurer. Dr. Benjamin Brewer, a family practitioner who writes a regular column for The Wall Street Journal, has observed, “Nobody I know would be willing to buy gas at an unknown price, only to find out the damage when the tab comes a month and a half later. But between the mind-numbing complexity of health-care charges and the reluctance of many in the health system to reveal their prices up front, you don’t have much of a choice.”(1) Because of government price controls there is no longer any such thing as a price that a doctor or a hospital holds out to the public in exchange for its services.
We have even eliminated the word price from our health care vocabulary, referring only to cost. We speak of the price of bread and the price of tires but the cost of prescription drugs. The inference is that some opaque back-office process in health care mysteriously determines an amount to be paid. Price is something that should be known upfront by both customer and seller. Cost is not.
Even the word customer has taken on a perverse meaning in health care. Ask drug manufacturers who their customers are. If you think they’re the patients who consume the drug, then silly you. The customers are the doctors who prescribe the drugs without paying for them or even knowing their price—I mean cost.
A fundamental problem in American health care is that it has eliminated any necessity for the consumer to know or care about price. Price would allow—almost require—a prospective patient to judge the value of what he is being offered against the offerings of other providers. He could then commit his financial resources by choosing the best value—the best combination of quality, convenience, customer service, price, warranty, and net cost after insurance reimbursements. Price would give providers an objective way to differentiate their services from their competitors’. Yet the current system virtually forces consumers and providers to ignore price. In health care, the rigidity and complexity of government regulations and corporate rules have replaced the dynamic alacrity of market-determined prices to allocate and quickly reallocate resources to meet the real health care needs of Americans. Once again, markets cannot function without clear price signaling to both buyer and seller.
Medicine Is Different
Another factor weighing against a market solution in health care is the widespread belief that it is somehow different from our other necessities of life. There has long been an almost mystical belief that consumers needn’t and shouldn’t make medical purchase decisions. That’s because only their doctors are supposed to know and follow the latest medical science to treat and cure them—even though most doctors don’t. This belief has been encouraged by a medical profession that has long portrayed itself more as priesthood than occupation. At its worst, it has been resistant to change, protective of even its worst members, and highly successful in maintaining its monopoly on medical services—characteristics that have ill served many doctors and their patients. They both deserve better.
The common assumption is that ordinary people can’t be relied on to make the kinds of decisions about buying health care that they make about virtually every other aspect of their lives. Instead, they must depend on the wizard behind the curtain—the doctors, employers, insurers, and bureaucracies—to decide what health care services they need and how much to pay for them. The medical industry is supposedly so different that technology is blamed for driving costs up, even though it has driven them down in virtually every other area of our lives.
Medical care can certainly be technical and complicated. We will never expect consumers to know on their own whether they need angioplasty versus a coronary bypass. But we also don’t expect them to know how their cars, cable TVs, or computers work. With access to the right information, consumers could certainly make informed choices about which cardiologists and surgeons provide the best diagnoses, treatment recommendations, and outcomes at the lowest prices.
There is abundant evidence that, given adequate information—including price—consumers can do just as well buying health care products and services as they do making their other purchases. Just look at the consumer markets for Lasik eye surgery, cosmetic procedures, over-the-counter drugs, and high-deductible health insurance plans. Employer and government-dominated health insurance blocks consumers from access to information on medical options, quality, and price. Consumers are allowed neither the clout nor the incentives to demand it and use it.
Fear of Markets
Another reason for our lack of focus on market solutions is the widespread fear and distrust of markets. The late University of Pennsylvania economist Herbert S. Levine wrote, “While the entrepreneur is a positive force in the dynamic growth of society’s well-being, he engenders social hostility because of the destructive aspect of [economist Joseph Schumpeter’s concept of] ‘creative destruction.’”(2) Creative destruction is the process by which innovative entrepreneurs create great value but at the cost of destroying older, less effective products and companies. Thus, as my friend Michael Rothschild has written, “Everyone wants the prosperity that markets yield, but no one wants to bear the risks implicit in market chaos. At bottom, this is why popular support for markets is so weak.”(3)
It is common to fear what we don’t understand, and the fact is that no one really understands why markets work—or periodically break down. Markets are human-based, complex adaptive systems that, by definition, defy comprehensive explication.(4)
Market-Based Health Care System
Many people mistakenly believe that our current health care system is already market-based, with insurance companies, drug manufacturers, doctors, and hospitals growing ever richer at the public’s expense. In fact, we have never in modern times had a true market-based health care system. Today’s private-sector players are merely playing by the rules of a horribly distorted game to maximize their own well-being—behaviors we normally applaud in a real market economy.
Medical Care As Public Good
A further complicating factor is that many policy advocates don’t believe medical care should be viewed as an economic good at all but rather a public good. Some view medical care as more akin to a fundamental human right, like free speech or freedom of religion, rather than a limited resource subject to the laws of price-mediated supply and demand. They believe that health care is something best provided free of charge to people, not purchased by them. It is a belief held by a lot of influential and otherwise intelligent people, and it is not a new phenomenon. It was the theme of the extremely influential Flexner Report in 1910, in which educational theorist Abraham Flexner stated, “The medical profession is an organ differentiated by society for its highest purposes, not a business to be exploited.”(5) This report set the tone for American medical training, practice, and regulation to this day. Related thinking in other industrialized countries has led them to adopt “socialized” health care systems that have removed most market roles altogether.
Mix all these ingredients into the health care batter, and you get a powerful combination of legislators, pundits, policy wonks, macroeconomists, presidential candidates, social theorists, and voters who think that government should ignore basic human economic behavior and bake in yet more government and corporate control. Their debates tend to focus on where and how much to increase that control—not on how to engage the time-tested ability of properly regulated markets, augmented by financial safety nets, to resolve these problems. Despite the repeated failures of government and employer interventions, these would-be reformers are now demanding even more government control and more employer mandates in the belief that this time we’ll get a better outcome for everyone. We won’t.
Many critics argue that we are a wealthy country that can afford to provide necessary care to all our citizens. I agree with them. But only to the extent that we can engage appropriately regulated market capitalism to do what it does best—allow self-interested individuals to choose how to allocate their own limited resources to purchase high-quality, affordable health care, including insurance for the expensive stuff that they can’t otherwise afford. Then, with the addition of comprehensive social and financial safety nets for those otherwise unable to participate, we can ensure needed care for everyone—effectively and efficiently and far more humanely than under our current system and at probably half the cost.
But if we continue to default to top-down, rules-based control, we will ensure that we will never be wealthy enough as a society to meet everyone’s medical needs and continue to improve our living standards. The inherent inefficiencies will eventually swamp whatever amounts of societal wealth we will ever be willing to allocate to medical care. We will increasingly be forced either to forgo other needs or to allow government to ration us into substandard medical care—perhaps to the point where future Harvard Business School students may indeed hope someday to have enough money to afford a heart transplant that some government functionary rules medically nonessential for someone of their advanced age.
The Goals of Health Reform
The first step to effective reform is to lay out a set of goals that we want health care reform to achieve. Although people may disagree on detail or philosophy, I think most would agree with, or at least reluctantly accede to, the following major objectives:
1.Universal insurance availability: Everyone in America should have access to affordable health insurance, regardless of individual health status or history.
2.Sustainable value and affordability: Whatever we do with health care reform, we must include mechanisms that will get spending under control while encouraging innovation and improving quality, all on a sustainable basis.
3.Free-rider prevention: Any insurance plan that allows anyone and everyone to enroll must also prevent them from gaming the system. They can’t delay making insurance purchases until they become ill and then receive more in benefits than they pay in premiums.
4.Voluntary participation: Many advocates of universal insurance believe that it is either necessary or desirable to require everyone to purchase health insurance. It is neither, for reasons I will explain in chapter 4.
5.Financial protection: Health insurance should protect people against the unaffordable costs of necessary medical treatments.
6.Choice of insurance, providers, and treatments: People want choice. They’re used to it elsewhere in their lives because it is functional. Choice acknowledges that different people have different needs, different priorities, and different financial means to meet those needs and priorities.
7.Portability: People should be able to keep their own health insurance policies, regardless of who they work for and whether they are unemployed, retired, eligible for government-sponsored coverage, or just taking long sabbaticals.
8.Personal responsibility for prevention: Health reform should include incentives for people to manage their own health risks, like obesity, smoking, alcohol abuse, blood pressure, cholesterol, blood sugar, and other individually controllable risk factors.
I’ll discuss these goals in more detail in chapter 9, but now I must comment on their underlying focus on consumer control. Many people will tell you that the current medical system’s focus is already on the patient. But seeing people as patients rather than as consumers or customers is actually part of the problem. The word patient is derived from the Latin patiens meaning “one who endures,” a definition that could hardly be more appropriate for today’s medical consumers. Viewing people this way puts them into a subordinate role to providers—and to insurers, governments, and employers. Yes, the patient is the focus of the current system—and many of the proposed ones—but more like an animal in a zoo is the focus of spectators, patrons, handlers, veterinarians, administrators, and fundraisers. A captive panda may indeed be the point of all these resources, but it hardly has a say in how it is treated. Consumers are too often viewed in a similar paternalistic way by our health care system. It assumes that it knows better than they what they need, what they can have, and how much they have to pay. We need a health care system that provides the information and the clout that allows people to make their own choices about what they consume and from whom. They should not be dependent on the benevolent intentions of others.
Those are the goals I propose for health care reform. Now let’s see how we can create a workable consumer market to achieve them. I propose a concept I call the American Choice Health Plan. Its purpose is to engage regulated market forces to the maximum practicable extent as the most cost-effective means to funnel scarce health care resources to everyone who needs them. The following discussion provides a summary overview of American Choice, with chapters 9–12 going into considerably more detail.
The American Choice Health Plan
There are three essential reforms in American Choice. The first is to convert virtually all government and employer health insurance from the current defined-benefit group structure to a defined-contribution individual structure. Second, tax reform will extend to individuals the same favorable tax treatment currently available in health benefits provided by employers and government agencies. Third, insurance reform will allow a market for universally available, affordable, fully portable, individual health insurance to emerge on a self-sustaining, long-term basis.
Under American Choice, the government’s ongoing role will change to one in which it will do two things—and refrain from doing a third.
- Regulation: First, the plan will establish and enforce a set of boundary rules, including tax reform, that will allow a private insurance market to emerge permitting all American residents to purchase health insurance to cover otherwise unaffordable, necessary medical care. This includes modifying or abolishing all current government and corporate programs and regulations that are in conflict with this approach.
- Safety Nets: Second, the government, augmented by private charitable organizations, will provide essential social and financial safety nets to protect the minority who can’t otherwise participate in such a market on their own. Thus, government would continue to fund health benefits for the elderly, the poor, and the disabled—the traditional constituents of government-funded health care programs—but on a defined-contribution basis in the form of restricted cash payments. These would allow each individual to purchase his or her own health insurance in the same insurance market as everyone else.
- Laissez-faire: The third requirement is probably the most difficult. Government, having created a regulatory framework within which the market can finally function, must then be laissez-faire—that is, it must leave consumers, insurers, and medical providers alone to make all the pricing, production, and purchasing decisions among themselves. Here the government can help most with, as Thoreau put it, the alacrity with which it would get out of the way. That would then allow Adam Smith’s invisible hand to do its magic.
The government’s legitimate roles would be those of rule maker, fair referee, enforcer, and safety net of last resort—not insurer or regulator of prices or benefits.
If there is a fundamental problem with this approach, it is not technical, actuarial, or financial—it is political. Although we know markets work in practice, too many influential politicians and policy wonks don’t believe they work in theory—at least not for health care. The difficult task will be to transcend that way of thinking.
How the American Choice Health Plan Works
All employers and government agencies, such as Medicare and the state Medicaid programs, will get out of the insurance and benefits administration business entirely. That means no more setting benefits, premiums, or provider reimbursement rates—or choosing and paying medical providers. Instead, they will directly fund their constituents to enable them to purchase their own individual health insurance policies from private insurers and to buy their own health care services from their own choices of health care providers.
Tax equity will be achieved by allowing consumers to establish what I call health funding accounts (HFAs) that will receive these funding contributions on a tax-exempt basis and to which they may contribute their own funds, particularly when self-employed. HFAs are conceptually similar to today’s Health Savings Accounts (HSAs) but are more comprehensive in scope. HFAs will allow individuals to receive the same tax treatment now given to employer health plans and will become the central funding mechanism for all of an individual’s health insurance and health care purchases.
Reform of the insurance market will allow everyone to have access to many choices of private insurers, benefit options, and prices. Insurer participation will be voluntary, but participants will be subject to American Choice’s regulatory regime, which will not allow any participating insurer to turn anyone away or discriminate on the basis of health status, history, or genetic predisposition. Consumer participation will also be voluntary, but a choice not to participate will carry with it substantial short-term and long-term financial and health risks that must be borne by the individual.
Private insurers participating in American Choice will be free to offer whatever kind of coverage at whatever premium levels in whatever markets they wish. The benefits, however, will have to meet minimum requirements for continuous creditable coverage. In essence, that means no qualified insurer may offer cut-rate, low-ball benefit plans that deny coverage for unaffordable, medically necessary services.
Each consumer, regardless of health status or history, will be eligible to purchase any health plan she chooses, making her own judgments as to the mix of benefits, premiums, terms, insurer reputation, and allowable providers, all depending on her own financial resources and HFA balances. After choosing her initial plan, she will then be able to change to any other qualified plan once each year, during open enrollment periods. Based on the experience of Medicare Part D, the Federal Employees Health Benefit Program (FEHBP), and countries such as Switzerland, France, and Germany, each American consumer will most likely be able to choose from as many as several hundred different private plans each year, which will ensure all individuals have access to plans that would best meet their particular needs and circumstances. FEHBP, for example, offers 269 different health plans across the country. Even tiny Switzerland’s health care system offers ninety different private health plans to its citizens.
Consumers will be able to elect to purchase insurance that covers only high-cost health care, letting them pay directly for doctor visits, lab and X-ray tests, and most prescription drugs with their HFA funds. Or they might choose to purchase integrated insurance and primary care prepayment coverage, such as the Kaiser Foundation Health Plans offer. It will be up to each person to decide.