Tuesday, January 24, 2006

Health savings accounts

Bush is reportedly going to make expanded health savings accounts (HSAs) a central part of his State of the Union address. At this point, it's about the only big-sounding domestic initiative that he can plausibly try to conjure up. This would apparently be coupled with people's choosing high-deductible health insurance plans. E.g., you put $2,000 in the plan, pick health insurance with a $2,000 deductible, and then you are actually paying medical expenses out of your own pocket, albeit with tax-deductible cash. (To make it really out of your own pocket, the HSA rolls over and becomes an expanded retirement saving account.) We already have something along these lines in the law, but presumably he'd expand it significantly.

I have a lot more sympathy for the idea of making people cost-conscious in their healthcare expenditures than many in the liberal blogosphere do. But - it's not clear to me how well this low-information market, in which people don't really know what they need to and are being instructed by medical professionals with incentive structures of their own, can really function even with greater cost-consciousness.

Another criticism in the liberal blogosphere is that Bush, as usual, is trying to save big companies money. The idea is that the high-deductible insurance, which they presumably still pay for, gets cheaper, while the workers are paying more out of pocket. This is only a transition effect (wages and so forth should presumably shake out to a similar equilibrium as before), but politics is all about transition effects, and I suppose companies might gain big time as the adjustment occurred, depending on how locked-in the current terms of employment are in the short term.

To my mind greater cost-consciousness ought to help, although perhaps not as much, in the healthcare industry, as one would like to think. When it does help, while less medical services are being consumed, presumably that reflects that they weren't actually worth the out of pocket cost to the consumer.

One big problem with the Bush plan: as always, is bigger deficits and a worsened fiscal gap. Plus, gaps in insurance coverage would remain. More generally, the pooling of health risks, which is unambiguously socially desirable insofar as the risks are exogenous (not affected by the patient's behavior), and mixed rather than all bad even when it's endogenous, is not helped by the plan and possibly would get worse.

There are 2 potentially sane answers to the healthcare cost expansion crisis. The conservative idea is risk-adjusted vouchers. If A figures to cost the health insurance company $1,000 more a year than B, A's voucher to use towards purchasing the insurance is $1,000 higher. Economist Laurence Kotlikoff advocaes this approach, and the Bush I Administration was working on it for possible consideration after the 1992 election. The problems with this approach are (1) it still requires healthcare markets to work reasonably well in terms of consumer choice, and (2) it requires healthcare markets NOT to work so well that the insurance companies can outsmart the government and cherry-pick the people who are the best risks for them given the gap between voucher differences and actual risk differences.

The other idea is national healthcare, as Paul Krugman keeps advocating in the NY Times. I spent enough time at the University of Chicago to approach this as a huge skeptic. But other countries that provide it do indeed appear to get just as good (or better) healthcare results as we do, adjusted for all relevant variables, for a much lower GDP share and per capita cost. The government solution doesn't have to be absolutely good to be worth considering, just good given the alternatives.

Of course, when you think about how utterly corrupt and depraved our political system is these days (with the Medicare prescription drug bill being Exhibit A through Z), you have to wonder. This is a bill that apparently arbitrarily excludes particular drugs from coverage just because some lobbyist or other, presumably working on behalf of a rival product, got it excluded with no explanation or rationale. We know for certain that, if the current Republicans in Congress designed a national healthcare plan (anathema though this would be to them), they would make it so horrendously bad that the days when doctors bled their patients would acquire a gauzy nostalgic haze by contrast. So the question is how much better legislation written by future Congressiones would be. Are the current Republicans exceptionally depraved when measured against the future as well as the past? Or are they merely the harbinger of how, from now on, things are going to be? I'm not sure I want to know.

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J. Brose said...

Just found your blog and love it (I'm a former tax student of yours). I was wondering the following. Is it really true that other countries achieve better or the same results than we do? Whenever I hear a Krugman or Kristof make this argument they always cite infant mortality statistics as if that were somehow the only criterion for judging the quality of a healthcare system. Also, I suspect that the U.S.'s high infant mortality rate has litte to do with the quality of care and everything to do with high rates of substance abuse in the inner cities. Also, do the studies which compare costs of single payer systems versus ours factor in the "cost" of having to wait for certain procedures and also the "cost" of restricted choice in physicians? I'm just wondering. It's virtually impossible to find real, unbiased answers to these questions in the media, which is always biased in one way or another. I was hoping you could make some sense of this.

Daniel Shaviro said...

I've talked to healthcare economists who don't seem to have an axe to grind and aren't doing politics who agree. The stats are supposed to adjust for all relevant differences in demographics et al. One point to keep in mind is that this isn't a comparison of a market system with a government-run system, because the U.S. system is so heavily government-subsidized. Markets, to do great things, require well-informed consumers who are bearing their own costs. How well-informed healthcare consumers in the U.S. are (or could be) is debatable, but certainly those on Medicare or with overly first-dollar employer-provided plans aren't bearing their own costs.

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