In Health Care, Nobody Knows Anything
Two new industry studies reignite the debate about what makes health care so expensive.
"Nobody knows anything," is the famous dictum that screenwriter William Goldman once asserted about Hollywood movie-making. Goldman was saying that movie producers have no clue about whether or not a movie will sell until it hits the theaters. There is no formula for a hit movie.
Figuring out health care in America is only slightly more complicated and mysterious than making a hit movie. Fifty million Americans are unable to buy health insurance and premiums have doubled over the past decade. Health care spending in 2009 consumes about $2.5 trillion, more than 17 percent of our gross domestic product. And as spending has skyrocketed, improvements in health outcomes have been real, but modest. What's going on?
On Saturday, President Barack Obama denounced two new studies, sponsored by the health insurance industry, which found that current health care reform bills in Congress will increase premium prices for consumers. One study, done for the lobbying group America's Health Insurance Plans by the consultancy PriceWaterhouseCoopers, found that the provisions in the Senate bill sponsored by Sen. Max Baucus (D-Mont.) would add $1,700 a year to the cost of family coverage in 2013 and $600 for a single person. By 2019, family premiums could be $4,000 higher and individual premiums could be $1,500 higher. A weak individual coverage mandate, coupled with a guarantee issue requirement, no preexisting condition limits, and no rating based on health status would significantly boost insurance premiums.
The Blue Cross Blue Shield Association commissioned a new study by the Oliver Wyman consultancy which also found that guaranteed issue and community rating mandates coupled with a weak individual mandate would drive up premiums by 50 percent for individual policies and 19 percent for small group plans.
"Every time we get close to passing reform, the insurance companies produce these phony studies as a prescription and say, 'Take one of these, and call us in a decade,'" declared the president. "Well, not this time."
The president is right that we should always be skeptical of studies that find in favor of the groups that sponsor them. And these two insurance industry-sponsored studies do have their flaws. But the finding that guaranteed issue and community rating mandates increase insurance premium prices has been corroborated by other academic researchers. For example, researchers from MIT, the Brookings Institution, and Brigham Young University reported in a 2008 study published in Forum for Health Economics & Policy that community rating regulations increased premiums for high-deductible policies for individuals by as much as 17 percent and families by as much 33 percent in the nongroup market. In addition, the researchers found that the "guarantee issue regulations that accompany community rating regulations in New Jersey are associated with premium increases of well over 100 percent for individual and family policies." And as my colleague Peter Suderman recently pointed out, Massachusetts, the one state that combines an individual mandate, community rating, and guaranteed issue, now has the highest premiums for family insurance plans in the country.
President Obama also denounced the insurance industry malefactors for "making this last-ditch effort to stop reform even as costs continue to rise and our health care dollars continue to be poured into their profits, bonuses, and administrative costs that do nothing to make us healthy—that often actually go toward figuring out how to avoid covering people."
Obama is right that administration costs can be quite large. Why would health insurers spend so much money on administration? According to the New England Journal of Medicine, the director of the Office of Management and Budget, Peter Orszag, cites evidence that $830 billion is being spent this year on unnecessary care. That represents about 30 percent of all health care spending. Of course, insurers have a big interest in trying to reduce unnecessary spending, so they hire flocks of administrators to negotiate lower rates and to monitor medical spending charged by doctors and hospital administrators. Government health care programs like Medicare don't have to negotiate; government agencies just fix prices, which means they fail to combat waste and fraud effectively.
What about those insurance company profits? Back in July, President Obama asserted that health insurance companies are making "record profits." Not really. The Annenberg Public Policy Center's FactCheck.org reported, "In general, the health insurance industry did poorly toward the end of 2008 and in the first quarter of 2009, so record profits weren't likely in the second quarter." Averaging profits of 3.3 percent, health insurers are the 86th most profitable industry in the U.S., well behind chain restaurants (7.7 percent), electric utilities (6.2 percent), and brewers (18 percent), but ahead of major auto manufacturers (-3.3 percent), resorts and casinos (-8.9 percent), and major airlines (-11 percent).
We'll pass over the president's naked attempt to provoke voter envy about the big paychecks of health insurance executives, since taxing them away entirely would not perceptibly lower the costs of health insurance.
So why have health costs, and especially health insurance premiums, skyrocketed since 2000? Let's look at one plausible theory: market consolidation. In the past two decades, fewer and fewer competitors are exercising more and more monopoly control over health care spending. Case Western Reserve political scientist Joseph White looks at the last time a Democratic administration pushed for health reform. In 1993, recalls White, "costs were expected to quickly hit 14 percent of GDP and rise to 18 percent by the end of the decade." But that didn't happen. Why? One plausible story focuses on the rise of health maintenance organizations (HMOs).
The rise of HMOs was enabled by an earlier federal government attempt to rein in health care costs, the Health Maintenance Organization Act of 1973. The idea behind HMOs was that these insurers would control costs by offering a wide array of preventive care to their subscribers. That sounds like a plausible idea until one realizes that people, on average, change insurers every four years or so. An insurer that invested in preventive care was unlikely to reap the cost-saving benefits. Thanks to the spread of HMOs, the 1990s saw the rise in health care expenditures slow down. Why? Chiefly because HMOs fiercely negotiated lower prices from physicians and hospitals. But the era of modest premium price increases didn't last long.
Hospitals and physicians struck back by beginning to consolidate themselves. As hospital mergers produced local monopolies, they were able to increase their prices substantially. "I find that hospitals increase price by roughly 40 percent following the merger of nearby rivals," Leemore Dafny, an economist at the Kellogg School of Management at Northwestern University concluded in a 2008 study. Insurers with relatively few patients could not bargain effectively with the new local health monopolies, and so dropped out of those markets.
According to White, the result of the 1990s orgy of insurer and provider consolidation was that "there were half as many health plans in 2004 as in 1996." In addition, "in thirty-eight states the largest firm controlled at least one-third of the insurance market; in sixteen states it controlled at least half." In this analysis, insurers and hospitals have evolved into local oligopolies. One plausible story, it seems, is that an ever more monopolistic health care system has been fueling the recent double digit increases in health care costs.
But then you remember, nobody knows anything when it comes to health care. In 2003, the Federal Trade Commission issued a report that concluded that there was "no valid empirical basis" for the claim that consolidations among hospitals "have accounted for increases on hospital services." But what about consolidation among insurers? "The insurance industry is congenitally weak in bargaining with supply side of the American health sector," explained Princeton University health economist Uwe Reinhardt on a recent NPR Money Planet segment. Reinhardt believes that insurers largely dance to the fiscal tune whistled by hospitals and physicians.
Clearly there has been a drastic failure of market competition when it comes to the health care sector. The question is how can market forces of competition be brought to bear on escalating health care costs?
An essential player is absent from the competitive field: the actual consumer of health care services. So long as insurers can extract their premiums from employers and providers can extract payments from insurers, the health care industrial complex has very little incentive to rein in costs.
Recent efforts have been made to create so-called consumer-driven health care based on high deductible insurance policies. Because consumers are on the hook for the first several thousand dollars in health care costs, the idea is that savvy consumers will shop around for health care services and thus force insurers and providers to lower their prices. This cost-reducing dynamic works in most other areas of our economy, so why not in health care?
One of the chief problems is that consumers haven't a clue about what their insurance and medical services cost. Hospital chargemasters (essentially comprehensive lists of all charges) typically contain prices for over 20,000 items and services. Sorting through those lists for the best prices would be impossible for consumers. But why should they have to? In markets, the proper dictum is that "nobody has to know everything." Markets are superb at gathering widely dispersed information and resources from millions of people and firms and then distilling that information into prices.
When someone buys a car, they are not confronted with a bill listing separate prices for pistons, radiators, assembly line screw tightening, seats, gas tanks, windows, and so forth. Nor when they buy a hamburger are the prices for the beef, bun, wrapping paper, and special sauce listed and charged for individually. The market has bundled those separate items together into a single price. Competition sparked by consumer demand could unleash a similar simplifying dynamic in which prices for health insurance and medical services become bundled and more transparent.
So what kind of real reforms could increase health care competition? Congress should aim to break up the system of local monopolies into which our health care sector has devolved. In his Saturday attack on health insurers, President Obama noted that the industry enjoys "a privileged exception from our anti-trust laws, a matter that Congress is rightfully reviewing." What he is talking about is the McCarran-Ferguson Act of 1945 that allows state governments to regulate the business of insurance without federal government interference. The Act is, in part, responsible for the evolution toward state insurance markets dominated by just a few large insurers. Consumers cannot purchase insurance policies that are not licensed by their state insurance commissions and which do not incorporate all the mandates imposed by those commissions. Congress and the states should open up competition between insurance companies by enabling "regulatory federalism" that would allow individuals and employers to purchase health insurance from other states. As a report from the free-market Cato Institute notes, regulatory federalism would force state insurance commissions to compete among themselves. The result would be that "states that impose unwanted regulatory costs on insurance purchasers would see their residents' business—and their premium tax revenue—go elsewhere."
Barriers to increased competition among health care providers must be removed too. For example, many states have certificate of need programs that forbid the construction of new health care facilities without prior regulatory approval. Passed by Congress in 1974 as a cost-cutting measure, the ostensible purpose of the programs is to keep health care costs low by requiring advance approval by state agencies for most hospital expansions and major equipment purchases. But regulations don't really work that way. "Market incumbents can too easily use [certificate of need] procedures to forestall competitors from entering an incumbent's market," according to a 2004 Federal Trade Commission report. In fact, "programs can actually increase prices by fostering anti-competitive barriers to entry." State enforced monopolies increase prices? Who knew?
There is one thing that everybody should know when it comes to health care: Competition in markets tends to lower prices and improve quality over time. It can do so in health care markets as well.
Ronald Bailey is Reason magazine's science correspondent. His book Liberation Biology: The Scientific and Moral Case for the Biotech Revolution is now available from Prometheus Books.