What To Do About Health Care
In the 1970’s, an East German defector to the West was assigned the task of helping other escapees adjust to life in a free country. The problem, he remembered years later, was that from kindergarten through college, from the moment the newspaper was opened in the morning to the moment the radio was turned off at night, every East German was bombarded by state propaganda telling him that the West was afflicted by hideous poverty, unemployment, and crime. As a result, East Germans naturally concluded that in the West poverty, unemployment, and crime were completely unknown.
In the same way, after two years of hearing President Clinton insist that health care was the gravest problem the country faced, it was natural for the President’s political opponents to conclude that health care is one subject they need never think about again. A consensus has rapidly formed that Clinton’s health-care campaign blighted his presidency. Americans are by and large content with the care they get. They mistrust federal plans to tinker with that care. And other social problems—crime, welfare, immigration—worry them far more. Would it not be wiser to leave the vexed thing alone?
Unfortunately, the mere fact that President Clinton identified health care as an urgent national problem does not automatically prove that it is not an urgent national problem. It is, and will remain so.
Yet the persistence and intractability of the health-care problem should not rehabilitate the President’s plan. Looking again at this plan, and at the torrent of papers and articles that explicated and defended it, one can only gape at its arrogance and unreality. Apologists insist that it was by no means the socialist document it was represented to be, that it included a dose of market competition. Perhaps so; but this dose of competition was, in a curious sense, the ultimate hubris: the plan’s chief architects, Ira Magaziner and Hillary Rodham Clinton, regarded markets not as an infinite series of voluntary exchanges, but as a mechanism, as one more device for state control. They flattered themselves that they could introduce market-like arrangements where they pleased, bar them where they liked, and generally manipulate them to produce desired results.
Even that, however, does not quite convey the full ambition of the plan Magaziner and Mrs. Clinton wrote for the President. The Clinton plan in the minds of its authors aimed at nothing less than slyly reviving the dying hopes of liberalism. Thus: Health care would displace busing as a means of compelling racial integration, since the plan’s compulsory-insurance cachements would group cities and their inner and outer suburbs together. Health care would be the method for snuffing out the independence of university medical and science faculties, as state and federal officials determined which specialties would be taught, to how many students, and from which ethnic backgrounds. Health care would enable Washington to deliver colossal subsidies to favored business interests, by relieving unionized manufacturers of foolishly extended commitments and by offering smaller businesses below-market insurance at rates to be determined by the effectiveness of their lobbying. And health care would revive the Democratic party by proving to an increasingly skeptical middle class that Big Government could once again pay off for them.
Altogether, the Clinton health plan would have amounted to the most ambitious peacetime assertion of state power over civil society since the National Recovery Act of 1935. Its collapse must be reckoned as one of the closest shaves in the history of American democracy.
Good luck cannot, however, always be counted on. If Americans are to ward off future versions of the Clinton plan, or worse, believers in a free economy and free institutions must grapple with the same problem that Ira Magaziner and Mrs. Clinton did. Or, actually, the same five problems.
Health care is, in the first place, a budgetary problem. Together, Medicare (which goes to retirees regardless of income) and Medicaid (which goes only to the indigent) cost $55 billion when Ronald Reagan took office. Today they cost nearly five times as much. Hence, if the growth of the two biggest federal health-care programs could somehow have been held to the rate of inflation over the past decade-and-a-half, the federal budget would have been sitting comfortably in surplus today. Unless these two programs—and other health-care-driven programs like veterans’ benefits and federal employees’ retirement benefits—can somehow be brought under control in the future, it is impossible to imagine how the federal budget can be balanced and taxes cut.
Second, health care is an economic problem. Americans pay more than 13 percent of the national income for health care—more than any other major industrial nation. And the bills keep mounting at an unbelievable clip. One survey of large employers found that their health costs per employee more than doubled in the ten years 1984-93, from $1,645 to $3,781. Small employers’ costs have mushroomed even more dramatically. True, prices have come off the boil slightly over the past three years—but they are still rising faster than inflation and faster than overall economic growth. The exploding costs of benefits are gobbling up money that might otherwise have been paid to employees in cash: one important reason for the wage stagnation during the 1980’s boom.
Health care is also a social problem. The United States is aging rapidly. While the total population is expected to increase by about 20 percent between 1990 and 2030, the number of Americans older than 65 is expected to double. When Americans reach age 65, they enter a new country—one characterized by stark dependence on government. The tilting of the demographic balance toward the old therefore threatens to tilt the country’s social balance away from self-reliance and toward welfarism. And even before they reach retirement, many Americans do indeed suffer the anxieties that Mrs. Clinton so passionately described during the debate over her plan: anxieties about losing their insurance if they lose or change their job, and about insurers or employers arbitrarily changing the rules of the plans they rely on.
Inevitably, then, health care will again rise as a political problem. One thing, at least, Republicans should have learned from the Bush years—it is not prudent to tell voters who think they have a problem that they are mistaken. To be sure, most people like the care they get. A major survey done in 1993 on behalf of Novalis Corporation—a consultant to the managed-care industry—found that nearly 80 percent of Americans rated their own personal care as “good” or “excellent.” Only 5.4 percent rated the care they were receiving as “poor.” Startlingly, more than half of the uninsured rated their care as good or excellent. Even more startlingly, 55 percent of the uninsured reported that they enjoyed the services of a family doctor.
How can this be? For one thing, the typical uninsured American is not the widow Jones and her four hungry children: they are on Medicaid. The typical uninsured American is a high-school graduate looking for his first job, or a recently divorced woman waiting on tables while she tries to put her life back together. Sixty percent of the uninsured are under 30. Most of them will go without insurance for only a short time, just as they will go without employment for a short time: at any given moment, as many as 39 million Americans may lack insurance, but only 4 percent of the population are without it for as long as 28 months.
Since the uninsured are younger and healthier than average, and since state regulators have heaped so many minimum requirements onto private health-insurance plans, conventional policies represent a bad deal for most of these young people. If they could buy a bare-bones policy for $800 or $1,000, many of them might do it. But if forced to buy an expensive plan, they will wait until an employer purchases it on their behalf (not considering that he will submerge the cost by lowering wages).
Yet while Americans like the care they get, they feel no such enthusiasm for the national system as a whole. Only 45 percent rate the health-care system “overall” as excellent or good. Enough bad news has percolated through the population to persuade a majority to rate the nation’s healthcare situation, as against their own personal situation, as fair or poor. Which means that the malfunctioning of the system—its out-of-control costs, and the sense of powerlessness it inflicts on millions of consumers—will again sound a political echo.
Fifth, health care represents a moral problem for American democracy. Everywhere one looks, the distorted health-care market has created incentives for squalid behavior. Because Medicaid reimburses hospitals at absurdly low rates, they make up the shortfall by deliberately inflating the bills of their privately-insured patients. Because Medicaid covers nursing-home care and Medicare does not, and because Congress in 1988 enacted legislation that prevents Medicaid from investigating the assets of next-of-kin, old people can pass their assets intact to their children and then get cared for by the taxpayer. (This practice has become so routine that Senator Carol Moseley-Braun of Illinois won her race in 1992 despite the revelation that she had engaged in just such asset-shifting in order to qualify her mother for Medicaid.) Because the cost of insurance is escalating so rapidly, even conscientious employers are pressured to scale back the coverage they offer. And because welfare recipients are entitled to Medicaid but intact low-income working families generally are not, the failures of the American health-care market add one more temptation to the allurements of the dole.
These are big problems, they are urgent problems, and they are difficult problems. But anyone who wants to fix them has to begin by liberating his mind from the illusion the Clinton administration propagated about the American health-care system—the illusion that it is a free-market, private-sector system, and that its faults derive from the brutal appetite for profit.
In fact, health care is the sector of the American economy where government’s power weighs most heavily. The vast sums of Medicare and Medicaid money pumped into the health market since 1965 helped to spark the medical-cost inflation of the past 30 years. State regulation effectively outlaws cheap health-insurance plans by specifying a long list of services, from acupuncture to psychiatry, that any employer who decides to set up a plan must provide. But the most important of all the government-created distortions of the health market is the way health benefits are taxed.
Suppose you are given a $100-a-week raise by your employer. If you are a professional or managerial worker, you will be lucky to take home $55 of it after income and payroll taxes. If, however, that same $100 were spent to beef up your health insurance, every dollar of it would be available to you. For anyone whose health is not absolutely perfect, $100 of health insurance is more valuable than $100 in cash.
This distortion has twisted health insurance into strange shapes. Compare health insurance to automobile insurance. When you buy a policy, you pay a price calibrated to the riskiness of the car you drive and your own safety history. Automobile insurance is insurance—protection against big losses for which you pay a premium determined by the probability that you will incur such a loss. The policy does not cover new tires, tune-ups, or gasoline.
By contrast, health-insurance premiums are not much influenced by the riskiness of the actual people covered, nor does health insurance pay only against substantial losses. What are conventionally thought of as “good” plans cover eyeglasses, prescription drugs, check-ups, and other routine expenses. In other words, health insurance, for most Americans, is not insurance but a disguised form of salary. It is as if the federal government were to decide that money spent by employers to feed lunch to their employees could be deducted from taxes. And it is as if, instead of paying their employees and sending them out to get their own lunch with after-tax dollars, employers would set up lunchrooms and add asparagus and artichokes to the salad bar whenever profits improved.
Making health insurance a perk rather than insurance causes people to divert more of their income toward health care than they would otherwise prefer. If instead of giving me a raise, my employer juices up my health plan so that I can buy a new pair of eyeglasses every year, new eyeglasses are what I will take—even though I would rather have new shoes for the children or books or a little extra money for groceries.
Noninsurance health insurance also teaches people not to care about the price of the medical services they buy. In their remarkable book, Patient Power, John Goodman and Gerald Musgrave asked seven different Dallas-area hospitals the price of a complete blood count. The charge varied from $11 to $33. They found the same disparities for big-ticket services too: the normal delivery of a child could cost anywhere from $1,000 to more than $2,000. The same consumers who would drive across town to save a dollar and a half on a movie ticket neither know nor care what they pay for medical services, because the money they save belongs to their employer, not to them.
Worse, the value of the health-care perk varies not according to your health-care needs, but according to your income. If you are paying a 50-percent marginal tax rate, you would have to earn an extra $6,000 to buy a $3,000 health-insurance policy with after-tax dollars. If you are paying a 25-percent marginal tax rate, you would only need to earn an extra $4,000. Stuart Butler of the Heritage Foundation notes that the nontaxability of health-care fringe benefits amounted to a $48-billion tax expenditure in 1991, most of which was lavished upon the highest-income taxpayers.
Finally, so long as health insurance is thought of as a perk, it will remain a deal not between the consumer and the provider of health services, but between the provider and the consumer’s employer. Everywhere else in American society, the past fifteen years have humbled giant bureaucracies. Automakers, the phone company, television networks—every corporation that used to hand everyone “take-it-or-leave-it” deals has felt the new power of consumers who enjoy more information and more choices than ever before. But not medicine. There, consumers still approach bureaucracies as dependents and supplicants. Why? Because they do not control the money they are spending.
Whatever the Clinton plan’s other evils, it was not illogical. Clinton proposed to eliminate the health market’s inconsistencies by proceeding faster in the direction the country had been heading since 1965 toward fully state-controlled medicine. Unless his opponents can reverse course and pull the country back toward a free market in health care, something like the Clinton plan must someday prevail. The choice for America does not lie between the Clinton plan and the status quo. The status quo cannot be sustained. The real choice is between some variant of the Clinton plan and free-market reform.
So far, conservatives have produced three main approaches to health-care reform. In 1983, the Reagan administration sought to cap the increase in Medicare costs by stipulating in advance the amount it would pay to hospitals for 467 distinct procedures. Until then, hospitals had set their own prices more or less as they pleased, and mailed the bills to Washington. The Reagan caps did jolt the hospitals and did produce one-time savings. But as hospitals learned the system, the upward march of prices swiftly resumed.
Worse, while the Reagan caps failed to rein in Medicare, they succeeded in lowering the program’s standards of care, by setting reimbursement rates for many simple operations below the hospitals’ own costs without creating incentives for hospitals to restructure those costs. As a result, Medicare patients often fail to find hospitals willing to perform simple but important services.
The second conservative approach was the individual-mandate plan designed by Heritage’s Butler in 1991. Heritage figured that since everyone in the country was getting some form of health coverage anyway, everyone ought to buy it. But unlike most liberal schemes, the Heritage plan imposed the obligation to buy insurance not on employers but on individuals.
In order to make insurance affordable to poorer people, the Heritage plan would have Washington seize the $48-billion tax subsidy to the private-insurance market and redistribute it. If your employer paid $3,000 a year to buy you health insurance, that $3,000 would now count as “income” on your W-2. What you would get instead would be a tax credit for the purchase of health insurance, ranging from 20 percent if you had a high income to as much as 90 percent if you were very poor.
Thus, an affluent person who bought a $3,000 policy (and he would probably be buying it for himself since the government would no longer be giving his employer a tax subsidy to buy the policy for him) would be able to subtract $600 from his income tax. The remaining $2,400 he would have to pay out of his own pocket with after-tax dollars. That would make him a much more careful shopper. Meanwhile, a low-income person who spent $1,000 on a cheap policy would get a tax credit for as much as $900—and if that $900 exceeded the insured person’s income-tax liability, he would get a check for the balance from the IRS.
The Heritage plan would make insurance much more accessible while also inducing Americans to be a little more price-conscious. Upper-income Americans would care about price because they would be paying 80 percent of the cost of their insurance policies themselves with after-tax dollars. Lower-income Americans would care about price because—even though their out-of-pocket costs would nearly vanish—they would be obliged to shop for insurance policies on their own, rather than simply presenting themselves to a doctor who would bill Medicare or Medicaid.
Back in 1992 and early ’93, when some type of socialized medicine hovered ominously close, the Heritage plan looked like a daring free-market reform. As backing for the Clinton plan crumbled, though, the redistributionist features of the Heritage scheme cost it most of its support among Republicans. Libertarian-minded Republicans disliked ordering people to buy insurance, and conservatives generally gagged as they realized that Heritage’s system of credits would steepen the progressivity of an already redistributionist tax system—an especially sore point after President Clinton hiked the top federal-tax rate to nearly 40 percent (up from 28 percent just five years ago).
Because Medicaid and Medicare would continue to absorb virtually all the health-care costs of the poorest and oldest—in fact, these programs would take on even larger responsibilities—it is doubtful that the Heritage plan would do very much to reduce health care’s drain on the federal treasury. Nor would the Heritage plan affect the way Americans react to health costs. From the point of view of the consumer, not much would change: he would go on sending his medical bills to CIGNA or Aetna for reimbursement as he incurred them. All he would notice was that he was paying higher income taxes.
After months of intra-conservative pummeling, Butler surrendered his sword this winter. He co-authored an article in the winter issue of Policy Review, Heritage’s quarterly publication, with one of his severest critics, William Niskanen, retreating from the specifics of the 1991 plan to more general principles that nearly all free-market-minded people would accept.
Niskanen is president of the libertarian Cato Institute, and the principles he and Butler promulgated seem to point more naturally to the approach Cato advocates, and which has been endorsed by nearly 200 Congressmen: the medical-savings (or Medisave) plan devised by John Goodman and Gerald Musgrave of the National Center for Policy Analysis in Dallas. All the technicalities aside, it would work more or less like this:
The tax exemption for contributions by employers to health-insurance plans would be abolished in favor of tax-exempt Medisave accounts. Employees and their employers would make donations to these accounts, out of which individuals would pay for their routine medical expenses. Whatever was left over in the account at year’s end would remain the saver’s property. Over a number of years, reasonably healthy people would compound tidy nest eggs with which to finance their health costs in old age. In the meantime, they would protect themselves against serious illnesses by purchasing a new type of policy, one made available by the repeal of state and federal regulations controlling what a health-insurance policy must look like.
The new policies would carry very high deductibles—$3,000 a year. Since more than 80 percent of Americans spend less than $3,000 a year on health insurance, the premiums for these policies would be relatively low. Large savings could also be made in administrative expenses. As economists often point out, a $50 claim costs as much to process as a $50,000 claim. Under Medisave the vast bulk of medical costs would be paid without having to crank up the bureaucratic machinery of the insurance companies.
Over time, these Medisave accounts would eliminate the need for Medicare. As for Medicaid, it could be replaced either by a more modest version of the Heritage Foundation’s tax-credit scheme or else by direct payments by the government to Medisave accounts established for low-income people.
The tremendous advantage of the Goodman and Musgrave plan is that it would bring medical-cost inflation screeching to a halt. As people bought medical services for themselves, with real dollars that they could otherwise keep, they would suddenly start to shop as cannily for health care as they do for food and shelter and every other essential of life. There is no inherent reason that health costs must skyrocket: the prices of all other technology-intensive services almost invariably fall.
And the Goodman and Musgrave scheme would accomplish this while protecting the quality of health care: patients would no longer be subject to an insurer’s determination—or Medicare’s—of what they did or did not need. They could decide for themselves whether or not they required a third day in the hospital after giving birth; they could decide for themselves whether or not they wanted to pay for a policy that covered psychological trauma.
The weakness of the Goodman and Musgrave plan is that it pays comparatively little attention to the problem of insuring America’s poorest. Their Cato allies have suggested that the best answer to this problem lies in forming pools of high-risk people whom each state would pay private insurers to take care of. Twenty-eight states have already enacted something very like what Cato recommends. But this remains an inadequate response to the ever-mounting medical ills of America’s growing ranks of underclass poor.
What, then, to do? The four main goals of health-care reform are:
- To alleviate the burden that spiraling health costs impose on the federal budget.
- To alleviate the burden that spiraling health costs impose on private industry.
- To bring insurance within easier reach of the uninsured.
- To nip in the bud the deterioration in medical quality that has begun to manifest itself as employers and governments control costs with top-down administrative measures instead of competition.
The Goodman and Musgrave Medisave plan goes far toward accomplishing these goals. It ought to be the basic building block of any Republican reform. But it does not reach quite far enough. Four additional steps are needed.
First, Medicaid—the most rapidly growing and most abused federal-health program—should be reconceived. Instead of being a piece of the health-care puzzle, Medicaid, along with the federal disability program, must be recognized as a piece of the welfare puzzle. Medicaid is already administered by the states, under widely varying rules. Indeed, one man—former New York Governor Mario Cuomo—is almost single-handedly responsible for the explosion of Medicaid costs. New York State, though it contains only 9 percent of the Medicaid population, gobbles up 18 percent of Medicaid spending. Congress should do with Medicaid what it is preparing to do with welfare: cap benefits at their present level, convert the money into block grants to the states, and repeal all rules inhibiting state freedom to experiment.
After all, the tragedies counted among America’s most horrific health problems—from premature underweight babies to AIDS-infected drug addicts to the twelve-year-old gunshot victims bleeding to death in lackadaisical ambulances—are not really health problems, any more than the plight of the homeless is a housing problem. They are incidents and by-products of the breakdown of social order among the urban underclass.
Thus, for example, the demographer Nicholas Eberstadt has demonstrated that even though ultra-low-birth-weight babies enjoy better odds of survival in America than in any other country, America still suffers a horrific infant-mortality rate because American mothers give birth to so many more low-weight babies than mothers in other countries. Eberstadt has shown that the most important factor in determining birth weight is the mother’s own conduct. Mothers who drink, smoke, eat badly, and take drugs during pregnancy will have low-birth-weight babies—and such mothers are highly likely to be unmarried. So long as the welfare system encourages illegitimacy, Medicaid could double its prenatal spending every single year and still fail to make a dent in America’s infant-mortality statistics.
Next, Washington must get out of the business of providing health care itself. The Veterans Administration (VA) is the single largest hospital system in the nation—and also a notoriously inefficient and shoddy one. Hospitals are located where long-forgotten Congressmen could profit politically from them. Costs are high, service quality is low. Everybody agrees that veterans have special claims on the public, combat veterans most of all. But those claims could be met, better and more cheaply, if Washington made extra contributions to veterans’ Medisave accounts so that they could buy an insurance policy of their choosing. And then the VA’s network of inefficient hospitals could be taken off the nation’s books.
As Washington turns Medicaid over to the states and veterans’ assistance over to the private sector, the states must likewise limit their own ambitions and abandon their habit of interfering in their medical markets. If an insurance company wants to offer a cheap plan that does not cover acupuncture, chiropractic, or replacement eyeglasses, it should be allowed to do so. If a health maintenance organization (HMO) wants to contract only with a specified list of doctors who agree to follow certain rules, it should be allowed to do that, too—without the state legislature forcing it to deal with “any willing provider.” The 39 million uninsured have money to spend. If permitted, the insurance companies will offer policies such people can afford. America has 39 million uninsured people for the same reason that it would have 39 million naked people if the only clothing stores permitted to operate were Bendel’s and Saks. We should legalize K-Mart insurance before concluding that the private sector cannot do the job.
Finally, America’s most permanent and intractable health problem arises from the most permanent and intractable fact of life: old age. It is expensive to be old even if you are comparatively healthy, and it is very expensive if you are not healthy. Beginning on or about August 15, 2010, the front wedge of the baby boom will turn 65. They are going to need hearing aids and prescription drugs and pacemakers and hip replacements and all the other wonderful contrivances of modern medical technology. And beginning on or about August 15, 2020, these baby-boomer retirees will need nurses and in-home care and, in the end, institutional care.
All that will require money—huge amounts of money. Whose? As things are going, the money will have to come from a penurious government squeezing all it can out of the baby-bust generation. This effectively guarantees that the baby boomers will receive low-grade care in their declining years. If, however, the money paying those nurses and buying the pacemakers is their own, they will enjoy an abundance of choices and eager service in health care, as consumers do in every other sector of a market economy.
In order to ensure that they have the money to spend, though, the baby boomers must begin at once, if they have not done so already, to save like chipmunks anticipating a hard winter. Doing that over the hurdles of a 39-percent top federal tax rate and a 28-percent capital-gains rate will be no easy trick.
Like everything else, then, the health-care problem turns out to be a corollary of the growth of the U.S. economy and the accumulation of private capital. Four years ago, the Heritage Foundation convened a conference to discuss whether tax reform was the key to health-care reform. It is, but not in the sense Heritage meant. Low taxes, and especially low taxes on saving, are the key to the health reform that matters most: enabling Americans to sock away the money they will require to buy care when they can no longer care for themselves.
As complicated as the American health-care story is, it can be summed up simply. Through its tax policies, and then through the invention of Medicare and Medicaid, the federal government has twisted the health-care market in ways that threaten the government’s own solvency and the profitability of every employer in the nation.
Measured in dollars, health care may present the most gargantuan example of unintended consequences in the whole sorry history of modern welfarism. Probably the harm done can never be fully undone. Still, it is possible to lay down the basic principles of a saner future for American health care: put control over health insurance into the hands of the insured, not their employers, and make the costs of insurance visible; get government at all levels out of the business of providing health care for the nonpoor, and get the federal government out of the business of providing health care for the poor.
If the American health-care system remains in its present form, it will, within fifteen more years, bring into existence an enormous voting bloc of retirees utterly dependent on the state for comfort and care in their old age. There is virtually no chance that the era of conservative government promised by the 1994 elections can ensue under those conditions. Hence the health-care argument is more than a technical one, more than an argument about regulations and spending and taxes. If the free-marketeers lose this argument, Medicare and Medicaid will ineluctably bring about a whinier, more dependent culture. If, on the other hand, the free-marketeers win, individual medical-savings accounts will not only make for a better health-care system but will also reinforce the thriftiness, self-reliance, and self-confidence of the American people.